James D. Slover, MD, with Ms. Maxine James. Dr. Slover is exploring whether adding an explanatory video to current counseling and educational efforts affects patient knowledge, comfort with shared decision making, or treatment choice.
Courtesy of James D. Slover, MD


Published 10/1/2011
Sally T. Halderman

Why do disparities in joint care continue?

OREF grant recipient studies reasons for racial, gender, economic disparities

James D. Slover, MD, aims to use his knowledge to ensure that all patients who seek care for hip and knee osteoarthritis have a solid understanding of the full range of available treatment options—including total joint replacement.

Research suggests that appropriate use of joint replacement may offer long-term advantages in quality of life and cost efficiency compared with other management strategies. Direct patient benefits are significant: greater preservation of mobility, physical independence, and better general health. But Medicare data show fewer total hip and knee procedures among both African-Americans and Hispanics than among Caucasians.

Dr. Slover notes, “Although the reasons for this low utilization are complex, patient access to adequate information about osteoarthritis, management options, and outcomes may play a key role in both their choice of treatment and their comfort level with participating in the treatment decision.”

With funding from the Orthopaedic Research and Education Foundation (OREF), Dr. Slover will document how patient baseline knowledge and feelings about shared decision making may differ by race, income, insurance provider, current functional status, and other factors. The study will further explore whether adding an explanatory video to an educational booklet and current pretreatment counseling affects patient knowledge, comfort with shared decision making, or treatment choice.

The project, “Factors impacting decision making in management of arthritis in an urban population,” is supported by the 2010 OREF/Smith & Nephew Research Grant in Adult Reconstruction. The Foundation for Informed Medical Decision Making produced the video and educational booklet.

“The potential for disparities in the practice of orthopaedic surgery is an issue of primary concern for our profession,” Dr. Slover said. “Although cost is an issue for our entire health system, current efforts to contain spending should not lead to differential care based on such factors as sex, race, economic status, or insurance type.”

Visuals to enhance understanding
Previous research has shown that patients evaluating spine treatment choices expressed a preference for and gained greater knowledge from a combination video-booklet decision aid than from a booklet alone. Similarly, video tools may enhance patient understanding of osteoarthritis management options.

Dr. Slover’s study will recruit participants at New York University’s Hospital for Joint Diseases, where he is an assistant professor, and other hospitals in New York City. Eligible volunteers must have been diagnosed with advanced osteoarthritis of the hip or knee and qualify as candidates for total joint replacement. The investigators will randomize patients to one of the following groups:

  • a control group that receives current standard pretreatment counseling and decision support with an educational booklet
  • a test group that views the decision-aid video in addition to receiving the standard instructions and booklet

As part of the research project, Dr. Slover’s team will first measure the level of function of each patient, using standard questionnaires. His team will also assess patients’ baseline knowledge of osteoarthritis and treatment options, expectations about outcomes, and willingness to share in decision making.

Patients in both groups will then meet with their physicians to review the potential benefits and risks of treatment choices. Members of the test group will also view the decision-aid video at home. All patients will return a few weeks later to continue discussing options and reach a treatment decision. At that return appointment, investigators will re-evaluate patients’ knowledge, expectations, and decision-making comfort level.

Dr. Slover’s hypothesis is that patients who viewed the video achieved greater knowledge and a higher comfort level with decision participation. He will also assess whether the video will help equalize the percentage of patients choosing total joint replacement across racial and demographic groups.

If the video achieves these goals, Dr. Slover will offer it for wide dissemination to orthopaedic patients. “This project directly addresses the need for equal access to care by exploring potential drivers of treatment disparities and testing a tangible tool to reduce them,” he said.

Essential grant support
“I couldn’t do this work without OREF funding,” Dr. Slover continued. “My grant supports hiring and training a full-time research assistant to handle the time-consuming administration of the questionnaires that will provide key metrics for the study. I’ve always worked at academic medical centers, and I love combining research with a busy clinical practice. But it can be a stressful balancing act.”

Dr. Slover has known about OREF since his orthopaedic residency at Dartmouth. He gained his first exposure to the world of outcomes research, evidence-based care improvement, treatment disparities, and health policy through an opportunity to study at The Dartmouth Institute.

“I’m passionate about improving how we as orthopaedists and members of a care team interact with our patients from the moment we meet them,” Dr. Slover said. “If they opt for joint replacement, we’ll have a lifetime relationship with them. We want to do everything we can to make their lives better for having come to us.”

Sally T. Halderman is a contributing writer for OREF. She can be reached at communications@oref.org