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Health-Care Bias Not Just Black and White

Sex, Location Are Also Factors in Popular Knee Replacement Surgery
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WebMD Health News

Oct. 1, 2003 -- Hundreds of studies have already documented that racial minorities often get lower-quality health care than whites -- even when they have similar incomes, age, condition severity, and insurance coverage. But the latest research to investigate these obvious disparities suggests the issue isn't as black and white as the patient's skin color.

Their sex and address also are big factors.

Even within the same racial or ethic group, a patient's sex has a big impact on whether they get government-paid knee replacement surgery, an expensive elective procedure typically performed on those with moderate to severe joint problems of the knee, Dartmouth researchers report in this week's issue of the New England Journal of Medicine.

For Women, Location Matters

After reviewing nearly 431,000 Medicare patients who had the procedure between 1998 and 2000, they find that overall, white women had the procedure only slightly more often than black women -- and black women had it performed more often in certain cities. But in those same cities, knee replacement surgery was done half as often or less on black men than on white men.

Those cities include New York, Los Angeles, Durham, N.C., Columbia, S.C., and others with large teaching hospitals or other facilities where the procedure is widely available.

Previous studies indicate that race matters in other procedures -- including certain types of emergency care for heart attack. Since whites get these treatments more often, doctor bias and access to care have often been cited as the likely reasons.

Historically, knee replacement surgery has been done more often on women, who have higher rates of knee osteoarthritis than men. But blacks are particularly vulnerable to degenerative joint disease -- one in three of the nation's 70 million arthritis patients are black. Yet in every region studied, black men are below the norm in getting this surgery.

Is it because black men are viewed as "worse" patients? Maybe, says the study's lead researcher.

"What we're hearing from some doctors is that when the procedure is suggested to black men, they often say 'No,'" economist Jonathan Skinner, PhD, tells WebMD.

Blacks Underserved

In February, another group of researchers measured race as a factor in which patients had knee replacement surgery and found that blacks underwent the procedure significantly less often than whites. They note in the journal Medical Care that white patients were significantly more likely to have had a family member or friend who had received joint replacement and therefore had a 'good understanding' of the procedure, while black patients were more likely than their white peers to believe that joint replacement would entail "at least moderate pain" and severely impair their ability to walk, at least temporarily.

"Before the Skinner study, most people who cared about this issue were wondering how much of this problem was due to bias on the part of the caregiver, or a distrust of minority patients toward their doctors -- but the mix of those and other factors wasn't clear," says James Knickman, PhD, of the Robert Wood Johnson Foundation, who wrote an accompanying editorial. "It turns out that it sometimes doesn't matter if you're black or white; it's geography and gender that matter."

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