Background/Purpose: Total knee replacement (TKR) is an effective treatment for persons with end-stage knee osteoarthritis (OA). Differences in offer, acceptance, and complication rates for TKR have been documented for racial minorities compared to Whites within the US; however, there has been no translation of these  differences into population level lossess of quality-adjusted life-years (QALYs).

Methods: We used the Osteoarthritis Policy Model (OAPol), a validated computer simulation of knee OA, to estimate QALYs lost in African American (AA) men and women compared to Whites (W) due to differences in TKR offer, acceptance, and complication rates.The data on complications, offer and acceptance of TKR were derived from published literature. TKR offer ranged from 10% in AA persons with advanced knee OA to 23% in White persons. Willingness to undergo TKR (acceptance) ranged from  58% for AA men to 84% in W men (Table). Published complication rates ranged from 4.3% in Whites to 6.5% in AA persons undergoing TKR. We validated OAPol model estimates using national data on TKR utilization from the Healthcare Cost and Utilization Project. Future QALYs were discounted at 3%/year. We estimated per person QALY losses due to differential offer, acceptance, and complication rates in AA men and women and calculated population-level person-years lost by multiplying QALY losses by the number of AA men and women with advanced knee OA in the US. Loss was defined as the QALY difference seen using AA rates of offer, acceptance,  and complication, compared to W rates. The population  size for those with advanced symptomatic knee OA was obtained from published data (310,000 AA men and 600,000 AA women).

Results: Current utilization of TKR leads to 16,000 QALYs gained for  AA men and 50,000 QALYs for  AA women (Table). The disparity between offer levels observed in  AA and W populations with advanced knee OA may lead to a loss of 71,000 QALYs for African Americans. The increased complication rates experienced by the AA population could lead to a loss of 3,000 QALYs. Assessing the combined effect of lower offer rate and increased complictions for the AA population reveals a QALY loss of 20,100 for AA males and 57,100 QALYs for AA women, leading to over 77,000 QALYs  lost overall.

Conclusion: Documented differences in TKR offer rates in conjunction with increased complication rates in racial minorities leads to substantial QALY losses. Increasing the offer of TKR among African American persons and decreasing the complication rates to levels observed in White populations may lead to additional 120% gains in quality-adjusted life years. Programs focused on decreasing the disparities in TKR offer and complications rates in African Americans with diagnosed advanced symptomatic knee OA are urgently needed and such efforts could result in large population-level benfits for racial minorities.