Disparities in Total Knee Replacement: Population Losses in Quality-Adjusted Life-Years Due to Differential Offer, Acceptance, and Complication Rates for African Americans

Arthritis Care Res (Hoboken). 2018 Sep;70(9):1326-1334. doi: 10.1002/acr.23484. Epub 2018 Aug 16.


Objective: Total knee replacement (TKR) is an effective treatment for end-stage knee osteoarthritis (OA). American racial minorities undergo fewer TKRs than whites. We estimated quality-adjusted life-years (QALYs) lost for African American knee OA patients due to differences in TKR offer, acceptance, and complication rates.

Methods: We used the Osteoarthritis Policy Model, a computer simulation of knee OA, to predict QALY outcomes for African American and white knee OA patients with and without TKR. We estimated per-person QALYs gained from TKR as the difference between QALYs with current TKR use and QALYs when no TKR was performed. We estimated average, per-person QALY losses in African Americans as the difference between QALYs gained with white rates of TKR and QALYs gained with African American rates of TKR. We calculated population-level QALY losses by multiplying per-person QALY losses by the number of persons with advanced knee OA. Finally, we estimated QALYs lost specifically due to lower TKR offer and acceptance rates and higher rates of complications among African American knee OA patients.

Results: African American men and women gain 64,100 QALYs from current TKR use. With white offer and complications rates, they would gain an additional 72,000 QALYs. Because these additional gains are unrealized, we call this a loss of 72,000 QALYs. African Americans lose 67,500 QALYs because of lower offer rates, 15,800 QALYs because of lower acceptance rates, and 2,600 QALYs because of higher complication rates.

Conclusion: African Americans lose 72,000 QALYs due to disparities in TKR offer and complication rates. Programs to decrease disparities in TKR use are urgently needed.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • African Americans / statistics & numerical data*
  • Aged
  • Arthroplasty, Replacement, Knee / adverse effects
  • Arthroplasty, Replacement, Knee / statistics & numerical data*
  • Female
  • Healthcare Disparities*
  • Humans
  • Male
  • Middle Aged
  • Models, Theoretical
  • Osteoarthritis, Knee / surgery
  • Patient Acceptance of Health Care / statistics & numerical data
  • Postoperative Complications / ethnology*
  • Postoperative Complications / etiology
  • Quality-Adjusted Life Years