Racial Differences in Utilization of and Factors Contributing to the Use of Knee Replacement Surgery as a Treatment for Severe Knee Osteoarthritis: A Scoping Review.

Objective: Differences in utilization of total knee arthroplasty (TKA) for Black patients with severe knee osteoarthritis (OA) have been well described. Understanding the factors that contribute to these differences is important when considering interventions to optimize TKA utilization. To evaluate these features, we developed a conceptual model for factors influencing TKA utilization and conducted a scoping literature review. Methods: Literature searches were conducted in April 2019 and April 2020 then updated in October 2022 and January 2024. Our primary outcomes were utilization of TKA for treatment of severe knee OA and factors affecting provider and patient decision making around TKA. We provide qualitative summaries of articles derived from our conceptual model. Results: Black patients have lower utilization of TKA for treatment of their severe knee OA than White patients with knee OA and worse pain measures at the time of surgery. Large secondary datasets demonstrate that Black patients have increased rates of revision surgery, higher rates of non-home discharges, higher readmission rates and higher episode of care cost. As reported in qualitative studies, Black patients have less favorable perceptions of the benefits of TKA and a lower degree of trust in the healthcare system. Recent policies to reduce cost and/or improve quality of care may have unintended impact on access to care for Black patients. Conclusion: There are racial disparities between Black and White patients at multiple steps in the decision-making process for TKA. Efforts to reduce these disparities will need to target multiple points contributing to this differential care.