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The Influence of Income and Race on Total Knee Arthroplasty in the United States
Jonathan Skinner, PhD1; Weiping Zhou, MS1; James Weinstein, DO, MS1
1 Center for Evaluative Clinical Sciences, HB 7152 Dartmouth Medical School, Hanover, NH 03755. E-mail address for J. Skinner: jon.skinner@dartmouth.edu. E-mail address for W. Zhou: weiping.zhou@dartmouth.edu. E-mail address for J. Weinstein: james.weinstein@dartmouth.edu
View Disclosures and Other Information
In support of their research for or preparation of this manuscript, one or more of the authors received grants or outside funding from NIAMS MCRC P60-AR048094 and NIA PO1-AG19783. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. Commercial entities paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated (Dartmouth-Hitchcock Medical Center, Dartmouth Medical School).
Investigation performed at the Center for Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, New Hampshire

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Oct 01;88(10):2159-2166. doi: 10.2106/JBJS.E.00271
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Background: The associations among income, total knee arthroplasty, and underlying rates of knee osteoarthritis are not well understood. We studied whether high-income Medicare recipients are more likely to have a knee arthroplasty and less likely to suffer from knee osteoarthritis.

Methods: Two data sources were used: (1) the 2000 United States Medicare claims data measuring the incidence of total knee arthroplasty by race, ethnicity, zip (postal) code income, and region (n = 27.5 million) and (2) the National Health and Nutrition Examination Survey (NHANES III) for individuals with an age of sixty years or more (n = 1926) with radiographic and clinical evidence of osteoarthritis. Logistic regression methods were used to adjust for covariates.

Results: At the national level, age-adjusted rates of total knee arthroplasty in the high-income quintile were no higher than those in the low-income group (odds ratio, 0.98; 95% confidence interval, 0.96 to 1.00). Within regions, access to care was better for high-income groups (odds ratio, 1.19; 95% confidence interval, 1.17 to 1.22). Racial disparities in arthroplasty were significant (p < 0.001); the odds ratio was 0.36 (95% confidence interval, 0.34 to 0.38) for black men and 0.45 (95% confidence interval, 0.41 to 0.49) for Asian women. There was no evidence of an income gradient for most clinical and radiographic measures of arthritis. The exception was a significant negative association between income and pain on passive motion (p < 0.05).

Conclusions: High-income Medicare enrollees are no less likely to have osteoarthritis than low-income enrollees but have somewhat better access to care. Racial disparities are more important than those that are attributable to socioeconomic status.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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