The Health Disparities in Osteoarthritis (OA) workshop brought together OA investigators with others who have expertise in health disparities to exchange ideas regarding how/why disparities in OA treatment and care exist and how they can be addressed. Panelists and speakers highlighted mechanisms through which behavioral and biomedical science integration can lead to better health in OA.
The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institute on Aging (NIA), and National Institute on Minority Health and Health Disparities (NIMHD) sponsored the workshop. It was organized by NIH staff and meeting co-chairs Drs. Arleen F. Brown (University of California, Los Angeles), Leigh Callahan (University of North Carolina at Chapel Hill), Kent Kwoh (University of Arizona), and Ernest Moy (Veterans Health Administration).
The meeting included breakout sessions designed to foster the exchange of ideas on how to address issues related to health disparities in OA. These sessions built upon workshop topics including interventions, dissemination and implementation, community, and societal influences. Workshop attendees were also invited to participate in a poster session.
The workshop was videocast and recordings of the first and second days of the meeting are available on the NIH videocast archive.
- Day 1: NIH VideoCast - Health Disparities in Osteoarthritis (Day 1)
- Day 2: NIH VideoCast - Health Disparities in Osteoarthritis (Day 2)
A brief article about the event, Workshop Explores Strategies to Tackle Health Disparities in Osteoarthritis, is also available.
Final Agenda: Health Disparities in Osteoarthritis Workshop Agenda
Participant List: NIH Health Disparities in Osteoarthritis Workshop Participants List
The workshop began with a welcome from the NIAMS Director, Dr. Lindsey Criswell. She thanked the co-chairs for their involvement in identifying the speakers and developing content for the workshop. She also discussed some of the documented health disparities related to OA and emphasized the importance of this workshop for promoting work in OA that can benefit everyone.
Session 1: Introduction to Osteoarthritis
Presentation: Clinical Manifestations and Epidemiology of OA (Dr. Kent Kwoh)
Osteoarthritis is characterized by inflammation and joint failure. The disease is relatively common, affecting 240 million people, and the numbers continue to grow. It is a disease that limits life and increases the risk of comorbidities. There is no cure for OA and there are no approved drugs for its prevention or treatment. The disease is marked by changes in joint structure.
Pain is a relatively common symptom in OA as are stiffness, loss of mobility, and functional limitations. OA may develop in young people, although incidence increases after age 50. Additionally, the incidence is greater in women compared to men. The prevalence of OA has also been studied through the lens of race and ethnicity. In self-reported arthritis cases, evidence suggests higher prevalence rates and related activity limitations in certain minority groups.
Racial and ethnic differences in radiographic and symptomatic OA have also been studied. The underlying pathophysiology may be different among racial and ethnic groups and such differences may contribute to disparities in OA, although more studies are being conducted related to those differences to ensure that they are not due to small sample sizes.
There are several research gaps. Much of the epidemiology of OA focuses on the knee and not other joints. Data on the epidemiology, e.g., incidence and prevalence of OA, in additional minority groups is limited. Finally, data on risk factors for OA is lacking in many racial and ethnic groups.
Presentation: Life Course and Disparities (Dr. Amanda Nelson)
Healthy People 2030 has specific arthritis-focused goals of reducing joint pain and work limitations and increasing physical activity and has similar goals for addressing chronic pain in general. Several barriers related to social determinants of health (SDOH) impact the risk and prognosis of OA, and Healthy People addresses these factors.
The CDC has published maps of disease incidences for conditions such as arthritis, diabetes, cardiovascular disease, and barriers to healthy aging. Through these, observations can be made about geographic areas of the country that have overlapping factors that relate to OA. One such map shows how rates of obesity overlap with lower rates of physical activity in the country, especially in areas with large, underserved minority populations.
Disparities in OA are only beginning to be understood. In terms of pain, Black OA patients reported more pain and poorer function. This may be partially explained by differences in socioeconomic status. Several life-course factors, such as workplace environment, also impact the onset and development of OA. One such factor to consider is the built environment for populations at risk for OA. Accounting for SDOH when designing lifestyle interventions could help to mitigate health disparities in OA, and studies of such interventions would need to include diverse populations.
Community-based participatory research is also important for addressing SDOH. Tailored interventions can be especially useful. For example, the STAART study engaged Black patients with OA in a pain coping program and found positive results in pain management. Existing interventions for OA can also be adapted to better address health disparities. One example of this is adapting Walk with Ease, an Arthritis Foundation program, to meet the needs of Hispanic populations by using simpler language and including motivational strategies, among other changes.
Gaps in the existing research include a lack of research in diverse cohorts and a need to focus on modifiable factors that could explain differences that are usually attributed to race.
Presentation: Interventions, Dissemination, and Implementation (Dr. Said Ibrahim)
Joint replacement surgery is the intervention for late-stage OA. Clinicians usually suggest joint replacement after conservative management fails, pain and disability increase, and more invasive treatment is needed. Joint Replacement is relatively effective when given to the right patient, at the right time. It is cost-effective and safe, and the results last decades. Joint replacement use has increased over time and continues to rise.
Many studies have analyzed health disparities that impact the use of joint replacement. These studies have explored differences in rates of total knee replacement between age, gender, and racial groups. One study analyzed the perceived usefulness of OA treatments between Black and White populations. The researchers found that Black populations perceived joint replacement to be less useful than White populations, likely due to differences in expectations and knowledge about joint replacement. This perception was coupled with a decreased willingness to consider surgery due to concerns about outcomes. The results of these studies suggest that patient perception is a potential target for intervention.
Using decision aids as an intervention with patients influences their willingness to consider joint replacement. There has also recently been research into using AI as a potential intervention for assessing knee pain. An algorithm used to analyze the assessment of pain in different racial and income level groups was published as one future viable intervention for reducing disparities in OA, although it only addresses a single factor, pain.
Looking to the future, the field of OA research could benefit from additional studies using evidence-based tools to focus on the dissemination and implementation of information about OA treatment.
The presentations in each session were followed by a panel discussion where attendees could ask questions of the presenters. The first panel discussion focused on questions regarding provider communication and the dissemination of information. Many important points were made regarding these topics.
For example, Physician-physical therapist communication is an area that needs further exploration. The impact of poor communication is not extensively researched, especially among different racial groups regarding OA treatment.
Health systems and the cost-effectiveness of the dissemination of information is another important topic. The Centers for Medicare and Medicaid (CMS) have been encouraging health systems to adopt shared decision-making tools, especially in OA management. However, education at a population level is needed to enable these tools to be utilized. Not every decision aid provides the same level of usefulness or accessibility.
Finally, the impact of racial differences in terms of pain perception and rating has not been fully assessed. Additional factors may affect how pain is reported.
Session 2: Osteoarthritis: Personal and Interpersonal Influences on Care- How do the following factors impact disparities in OA?
Presentation: Overview/Socioeconomic Status (Dr. Jeffery Katz)
Environmental conditions impact a patient’s quality of life, health outcomes, and risks. These SDOHs are measured based on a variety of data sources and can be assessed on an individual level or at an ecological/area level. Examples of individual factors include employment status, income, and education while ecological data can be employment percentage, percentage of people with income greater than the poverty level, and the number of single guardian households. When interpreting SDOH indicators, some researchers will use ecological indicators as a proxy for individual indicators. However, social theory suggests ecological indicators have a unique role in impacting individual behavior.
The Social Vulnerability Index (SVI) is a commonly used method of aggregating area-level data. The SVI uses census data from fifteen variables categorized into four domains to measure the overall vulnerability of a population. This can provide insights into SDOH in a community. There is rich literature analyzing the effect of SDOH on OA. Some of these studies measure additional adverse outcomes from OA, such as the percentage of activities limited due to arthritis.
However, information about the impact of SDOH on racial and ethnic disparities in OA outcomes is lacking. One analysis that could help to improve understanding the relationships between SDOH and OA in diverse populations is the stratification of race and ethnicity data in datasets on SDOH. Another research gap that could be addressed is distinguishing which outcomes are influenced by individual versus area-level SDOH. Additionally, field interventions could be extremely useful at both an individual and ecological level.
Presentation: Patient-Provider Relationship/Communication (Dr. Sandra Soto)
In OA care, many overarching communication issues occur between patients and providers. One major example of this is misaligned expectations around prescriptions and treatment. This breakdown of communication leads to a decline in treatment and care. Miscommunication is also partially a result of inconsistent education around OA. Limited health literacy, perceptions about race and ethnicity, and linguistic barriers can also contribute to a lack of communication between patients and providers. These barriers can cause patient skepticism and distrust in treatment. Poor patient-provider communication can lead to less treatment adherence and therefore poorer health outcomes.
Many potential areas for intervention are available to address poor patient-provider communication. Institutional resources such as direct services designed to meet the needs of patients may be used. One direct service is the provision of interpreters and health education materials to meet disparate language needs. Cultural homophily, the tendency for individuals to seek out those who are similar to themselves, can also be considered when designing and implementing treatment. Cultural homophily for some groups stresses the inclusion of family, acceptance of alternative treatments as viable care options, and working with community health workers. Community health workers are excellent resources for connecting with patients and their environment. Additionally, the use of institutional accommodations, such as changing clinic locations and hours, may be needed. Clinic-community partnerships can help to address issues of trust between patients in a community and their healthcare providers. They also help to increase providers’ understanding of the needs of the community.
Research gaps may be addressed by combining interventions to create multilevel interventions. Finally, cross-cultural education in health curricula is also important for addressing some of the communication issues and is a gap that may need to be addressed.
Presentation: Health Quality and Access (Dr. Catherine MacLean)
Health care quality encompasses any aspect of health care that affects health outcomes. Quality can be measured through structure, process, and outcome measures. Structural measures look at both physical structure and organizational structure in a facility. Process measures consider the treatments patients receive and are the most common measures. Outcome measures include measurements like complication rates, revision rates, and mortality rates. These quality measures weighed alongside the cost of care, can help to determine the value of the care.
Assessment of healthcare quality can help to direct quality improvement activities, facilitate public reporting, and enable value-based purchasing. All of this is done to improve the health of individuals and populations. Risk adjustments are oftentimes used to adjust quality measures for SDOH. They aim to make the measurement of health care quality equitable. This approach, however, has pros and cons. Advantages include the ability to measure performance tied to SDOH in ways beyond provider control. Disadvantages include potentially masking disparities, therefore limiting the ability to identify and improve problems.
Studies on value-based purchasing and social risk found that beneficiaries with social risk factors had worse outcomes on many quality measures. They also found that providers who primarily served beneficiaries with social risk factors tended to have worse performance on the quality measures. Also, data on beneficiary social risk is not routinely collected. Even so, high quality is achievable for disadvantaged populations. Based on these findings about the impact of social risk factors, the HHS Office of the Assistant Secretary for Planning and Evaluation made several recommendations for when to adjust for them. Most OA quality measures are not adjusted for SDOH, although that may change soon.
Other studies have measured access to hospitals based on race. These studies aimed to measure if treatment in hospitals represented minority populations in communities well. They compared state-owned and not-for-profit hospital systems and showed that racial inclusivity varies across hospitals. Racial inclusivity compared to the value of total joint replacement care has also been examined in many hospitals. These results categorize which major hospitals are in the top and bottom 50 percent of racial inclusivity rankings.
The importance of cultural homophily in patient care was emphasized in this panel discussion.
There is a need to balance cultural homophily and family involvement in patient care with the patient’s need for privacy. Cultural norms of healthcare privacy differ widely and patient care teams need to be mindful of this. With the incorporation of cultural homophily in patient care, patients also may feel more comfortable deciding when is appropriate to ask for privacy.
Session 3: Multiple (Social) Determinants of Health - How do the following factors impact disparities in OA?
Presentation: Lifestyle Influences - Physical Activity and Nutrition (Dr. Stephen Messier)
Lifestyle interventions can affect rural and urban populations differently. Health behavior can differ between communities due in part to factors such as access to proper nutrition, ability and access to exercise, and access to specialized healthcare. Disparities may also be related to access to medical insurance and prevalence of obesity and other co-morbidities
A study was conducted to examine the effects of geography on clinical outcomes in a randomized clinical trial of diet and exercise. The Weight Loss and Exercise for Communities with Arthritis in North Carolina (WE-CAN) study looked at diet and exercise over eighteen months in adults with knee OA, adults who were overweight, and adults with obesity. The study worked with three communities of different populations, one urban and two rural. Several variables were measured that were worse in rural communities compared to urban communities, such as pain, function, mobility, depressive symptoms, and quality of life. However, diet and exercise were shown to have the same positive effect on all the variables equally between rural and urban groups. This study highlights the importance of including rural and urban communities in clinical trials.
Presentation: Physical and Sociocultural Environment (Dr. Hyunjee Kim)
There are three surgical settings for joint replacement: hospital inpatient settings, hospital outpatient departments, and ambulatory surgical centers. In recent years, outpatient surgeries are increasing because they are now covered by Medicare, and are generally cheaper than inpatient surgeries. Additionally, patients’ out-of-pocket costs are higher in ambulatory surgical centers than in hospital outpatient departments and inpatient settings. Despite this shift, there is little research comparing inpatient and outpatient surgery outcomes.
In addition, few studies have analyzed the impact of health disparities on joint replacement surgery. Some data suggest, however, that Black patients are less likely to receive outpatient knee and hip replacement surgery than White patients. More research may be needed to establish the reasons for this trend. Additionally, it may be important to understand the effect of bundled payment programs on the use and quality of outpatient joint replacement. Studies of disparities in access to surgery and post-surgical outcomes of outpatient joint replacement would be helpful.
Presentation: Racism and Discrimination (Dr. Maurice Endsley)
In OA, there are several examples of health disparities affecting Black patients, stemming from differences in perception, treatment, and care. Discrimination impacts provider communication and can lead to medical mistrust. This mistrust can then lead to a delay in seeking care, non-adherence, and dissatisfaction. Empowering patients by discussing what shared decision-making looks like to them can help to address these issues. This requires understanding patients’ perspectives, including patients’ values, goals, and preferences.
Some areas to consider include asking patients how they view their experiences, how past patient healthcare has shaped their experience with healthcare, and who they turn to for advice. It is also important to consider what structural barriers may be impacting the patient. Microaggressions in medical care are also inevitable and acknowledging and addressing these issues are important steps in repairing the patient-provider relationship. Apologizing, expressing concern for the microaggression, and asking for feedback will help to remedy the situation.
Overall, it is important to understand the history of racism in America, call out racism when it is present, and engage with other providers when issues of racism or microaggressions arise. As a field, it is important to look at populations not historically centered on and to focus on empowering and giving voice to those groups. It is also important for providers to understand how they may sustain an oppressive system and look for ways to advocate for change.
Presentation: Health Care Systems- Medicare (Dr. Caroline P. Thirukumaran)
Total joint replacements are effective treatments for end-stage arthritis. They are mostly performed as inpatient surgeries although, as noted in Dr. Kim’s presentation, other venues can be used. There is considerable variability in the use, outcomes, and cost of total joint replacements. There are also widespread disparities that impact the use of total joint replacement surgery. As recently as 2017, the use of knee replacement surgery was significantly lower in Black beneficiaries compared to White beneficiaries. The use of surgery was also lower for poorer beneficiaries who were totally eligible for Medicare and Medicaid.
Due to the importance of joint replacement, Medicare has implemented various reforms to attempt to improve the quality of and reduce spending on these surgeries. These include the Hospital Readmissions Reduction Program, the Comprehensive Care for Joint Replacement model (CJR) that was designed to improve the quality of care and spending through a bundled payment reform for total knee and hip replacements, and Bundled Payments for Care Improvement. However, these reforms are not designed to reduce health disparities, and they may even unintentionally further disparities because they are not adjusted for social risk. Reports from several leading agencies have recommended adjusting for social risk in value-based purchasing programs such as CJR.
Several studies have examined the impact of CJR on disparities. These studies serve as empirical evidence that payment reforms may cause providers to selectively choose patients and exacerbate disparities. Therefore, risk adjustment and metrics to incentivize disparity reduction and reporting of disparity metrics may improve quality for certain populations. Adding disparity reduction as a third aim to CJR has been proposed, and in 2021 the CJR was redesigned to include an adjustment for social and clinical risk. Researchers have not yet examined the effects of this adjustment, and additional metrics may need to be implemented, but the changes to the CJR are a step in the right direction.
Topics on payment reforms, the WE-CAN study, physical therapy, and suggestions for reducing disparities all came up as relevant topics during this panel discussion. Several points were emphasized and clarified during this discussion.
As of now, there are few, if any, reports on payment reforms that have been stratified to look at disparities. The Hospital Readmissions Reduction Program may have reported some stratified data, but CJR does not have a stratification mechanism for reporting. This is a point to potentially consider in future reporting.
In terms of the WE-CAN study, the study adjusts routinely for discrepancies in the number of males and females between groups at baseline. This allows for sex adjustment of pain measurement. The study has only just concluded and now investigators would like to follow the patients after the study. While the interventionists were trained in social cognitive theory, no targeted counseling occurred for the groups. This is because the study was only measuring diet and exercise compared to no intervention. Populations were divided evenly between rural and urban groups, and the WE-CAN study collected racial data between Black and White patients. It did not look at the impacts of SDOH.
Looking at joint replacement and physical therapy, studies show that inpatients were more likely than outpatients to use additional treatments following surgery. This includes physical therapy after surgery. Additionally, for total payment, outpatient surgery was cheaper but for out-of-pocket costs, outpatient surgery was more expensive.
Finally, regarding designing a program to reduce disparities, leveraging existing administrative data while working to collect more granular data from patient-reported outcome metrics can be useful. Designing interventions for providers, as opposed to patients, helps to ease the burden on the patients. While there is a place for patients to learn more, providers also need to be made aware of biases and racism that affect the patient experience. Patient trust is one example of a potential adjustment tool that may be used in SDOH analyses.
Day Two began with remarks from the director of the NIMHD, Dr. Eliseo Pérez-Stable. Dr. Pérez-Stable welcomed everyone and explained the populations with health disparities as defined by the NIH. He also established that race and socioeconomic status are fundamental in determining health disparities. He offered suggestions for what science can do to reduce inequities. Dr. Pérez-Stable then presented the NIMHD research framework. He also highlighted key points about OA. He concluded with a portfolio analysis of OA-related grants and funding by NIMHD as well as an overview of research centers funded by NIMHD.
Session 4: Community Voices
Presentation: Patient Voice (Ms. Val Overton)
This presentation highlighted the personal experience of a patient with OA, Ms. Val Overton. She began with an overview of her health issues. She shared her physical and mental journey through the healthcare system, explaining how switching between various types of health insurance throughout her life has affected her treatment. She emphasized how living with pain can greatly impact daily life including sleep, finances, and social interactions. She explained that while her insurance provided her with a voluntary pain management course, no physician has provided a viable solution to her pain. She ended her presentation by sharing where she is in her health journey and what life looks like for her now.
Presentation: Physician Voice (Dr. Tuhina Neogi)
Osteoarthritis from a clinical standpoint is defined by tissue structure and disease pathology. However, for the patients, the illness relates to pain and the experience of living with it. This pain can cause difficulty functioning and is often widespread. Pain can disrupt sleep, affect mood, and affect cognition. People with OA make up a significant portion of people with chronic pain. OA, therefore, presents a large burden on healthcare systems.
Many factors influence pain in OA. Pain management strategies offered to patients, affirmation of pain, and referrals for joint replacement are all impacted by health disparities. To address these, it is essential to alter unintentional disparaging language and to offer multimodal approaches in patient education. It is also important to engage physical therapists as a form of first-line therapy and offer counseling about lifestyle choices. In practice, physicians should not expect to achieve zero pain for their patients and should instead focus on helping patients have realistic expectations and understanding patient goals. This involves developing an action plan, such as prescribing exercise and weight loss tailored to each patient.
Another important facet of care that physicians should consider is “minimally disruptive medicine”. This means working with patients to accommodate their lifestyles and living situations when weighing treatment options; life demands such as employment and caregiving responsibilities may impact patients’ abilities to undergo certain treatments, and resource scarcities may also be a limitation. This is especially important because resource scarcity and workload responsibilities disproportionately affect communities of color and people of lower socioeconomic status. Addressing the pathology of OA is not enough, treatment should focus on the whole person and their experience.
Presentation: Societal Voice (Ms. Jennifer Raymond)
Area agencies on aging are found across the country and provide resources to patients outside of a clinical setting. Such agencies, including one called AgeSpan, work to treat the whole person when it comes to chronic conditions like OA. This means focusing on the goals of the patient in relation to the goals of the provider.
AgeSpan is the recipient of a five-year CDC grant that focuses on disseminating arthritis-appropriate evidence-based interventions, promoting physical activity via counseling for patients, and raising awareness about arthritis burden and management. It uses an SDOH assessment to identify which factors may influence people in reaching their goals. Some factors include food access and security, social isolation, and behavioral health. The goal is to then determine which community resources can help alleviate these barriers. AgeSpan is an exemplar of how area agencies may assess individual risk factors and provide resources for patients to reach their goals.
The focus of this panel was a response to the three voices mentioned in the talks: patient, provider, and societal. This discussion proved useful in highlighting further areas that need research to be addressed.
Different priority research areas may help each of the three voices. There is a need for healthcare providers to communicate with one another to provide a harmonized treatment plan. Non-clinical practitioners and community outreach workers are important as well, especially the inclusion of those workers in Black and Indigenous People of Color communities. Physicians may also lack exposure to pain management training in medical schools. Additionally, there needs to be improvement in the clinical implementation of study results related to pain management in OA. Finally, physical activity and daily walking are important; even a little movement is better than none.
Reports from Breakout Sessions
Over the course of the workshop, participants were able to attend two of five breakout sessions to discuss different factors that influence health disparities in OA:
- Patient‐level factors
- Patient‐clinician level factors
- Health system and policy level factors
- Societal/social determinants
- Community‐level factors
Groups were charged with addressing the following questions:
- What opportunities (e.g., resources/systems) currently exist that can be leveraged?
- Of what currently exists, what is working well or not?
- How do we better disseminate and implement methods/processes that work well?
- How do we adapt/modify methods/processes that are not working well?
- Where are the gaps/opportunities and how best could these be addressed?
- From the discussion, are there things that can be addressed immediately as well as long-term goals?
Several overlapping themes emerged among the breakout sessions. One focus was on community resources outside of the traditional healthcare system. An example of this entailed working with community health workers as an additional component of a patient care team to better serve the patient’s needs. Other strategies for leveraging community resources included partnering with local community centers (e.g., libraries and civil centers) and engaging with local physicians as advisors when developing interventions. Patients need encouragement to seek out programs they may not be aware of within their communities.
Several sessions highlighted the importance of diet and exercise interventions and emphasized promoting those to patients. Interventions should be tailored to patients’ communities and cultures. Diet and exercise guidelines should be adapted to specific communities and cultures to ensure proven interventions are equitably distributed.
Expanding and fostering better communication between patients and providers was another major focus of the recommendations of the breakout sessions. Many sessions cited the lack of accessible, centralized resources for information about OA treatment as a gap to be addressed. A need for both provider- and patient-targeted resources was mentioned. One suggestion was expanding the healthcare team to include additional roles such as social workers, physical therapists, interpreters, and community health workers.
Many of the breakout sessions highlighted a need for standardized measures within the factor they were discussing. Each session emphasized the need to implement standard reporting practices for different elements of OA assessment, treatment and outcome analysis. This included measures within patient care teams, pain rating scales, a framework for analyzing social determinants of health, the inclusion of culturally competent instruments, and the adoption of patient-reported outcomes (PROMS). Also mentioned were the measurement of patient access to and comfort with technology and assessments of comprehension.
Language barriers in patient populations were discussed in multiple sessions.
Research results focused on OA and health disparities are a growth opportunity. This emerged from several breakout sessions, with each focused on the need for this data through their own lens. Groups mentioned the need for more diverse research populations several times. Other suggestions included using resources and methods from other fields that have evidence-based interventions to address health disparities, such as HIV or cardiovascular disease. Participants encouraged continued support for large studies that are collecting data from minority and underrepresented populations.
Individual Break Out Session Summaries
Patient Level Factors
This breakout session, moderated by Dr. Callahan, focused on the gaps and opportunities that exist related to patient-level factors. The session suggested several assessment measures to reduce the impacts of health disparities. These included, among other suggestions, assessments of patient learning style, comprehension, and access to technology. The importance of crosstalk among patients, providers, community, and health systems was emphasized.
The session also suggested increasing collaboration between a range of disciplines and fields interested in OA. This could supplement large research studies focused on health disparities that already exist. Additionally, the need for more minority and underrepresented populations in these studies was mentioned. Utilizing existing frameworks that outline SDOH, the group suggested researchers put together a position paper to guide future studies.
Finally, the session also included a discussion on community involvement. They explained how bringing local community members into the OA discussion will help to address specific population needs. In summary, the group emphasized how a long-term change in attitude towards minority patients and an emphasis on diversity in research will address health disparities at the patient level.
Patient- Clinician Level Factors
Moderated by Dr. Kent Kwoh, this breakout session focused on addressing health disparities in OA care and treatment from the lens of patient-clinician level factors. One central theme regarding current opportunities that can be leveraged for this goal was expanding the patient care team by including the utilization of additional clinicians and community-based workers. Other points included standardizing existing pain rating scales, measures, and protocols.
When discussing current opportunities for change, the group encouraged modifying and streamlining methods of patient-clinician communication. An important growth opportunity highlighted was addressing the lack of education and resources for providers on how best to improve patient care and interactions related to OA.
The breakout session was used to call attention to the lack of clinician and patient resources and the need for care recommendation adjustments based on the communities being served.
Health Systems and Policy
For the session on health systems and policy moderated by Dr. Ernest Moy, one of the main topics of focus was the adoption of patient-reported outcomes (PROMS) to develop clear OA management guidelines. The group also discussed the promotion of diet and exercise with the needs of diverse groups in mind. They suggested the integration of diet and exercise-based treatment with other chronic disease management and proposed studying the implementation of such programs as a measure of success.
The session also focused on barriers to joint replacement and their influence on health disparities. Proposed solutions included the reduction of biases related to payment as well as ensuring informed decision-making for patients. The group also proposed different means to address SDOH long-term, such as through community partnerships. There is also need for longitudinal studies to further analyze the costs of different OA treatments.
This breakout session provided recommendations regarding social and societal determinants that impact OA. Dr. Arleen Brown moderated the discussion, and the group highlighted several existing resources and changes that can be made to address health disparities. One example included expanding Electronic Health Records to incorporate social and gender identity variables as well as patient feedback. They encouraged the utilization of existing community-based resources (e.g., libraries, community centers, existing programs) to better serve patients.
The participants also considered opportunities for growth, including working with the needs of communities to tailor messages, taking a public health approach to making sure messaging is culturally relevant, and addressing systemic racism that patients may face. The group stressed the need for more data on vulnerable populations and therefore the need to increase diversity in the workforce and in studies pertaining to OA. They also expanded upon adjusting physical activity plans to work with the patient’s abilities and access to resources.
The immediate goals presented in this session included increasing funding for research directly related to addressing SDOH, engaging with communities and families of those with OA, and addressing risk factors that can lead to OA. The takeaway is that with community involvement, increased education and awareness of implicit biases, the gaps that contribute to health disparities can be mitigated.
Community Level Factors
This session, moderated by Dr. Patricia Jones, examined community-level factors, starting with ideas to expand upon current studies. The group recommended that existing studies can be leveraged to collect data on SDOH, both in OA and in other fields with experience in health disparities. They also shared the importance of communication and adjusting current systems. One suggestion was to include information in many languages and tailored to specific communities. They explained that to understand the needs of a community, local leaders could assist with both study design and dissemination of information.
Taking the time to understand the needs of local communities and collaborate within the structures of the population emerged as a central point of this session. To do so, the group recommended that data and instruments be examined for biases and cultural competency. The participants also called attention to disparities in funding and other systemic issues in study design such as a lack of diverse recruitment. Through establishing relationships with community centers, reaching out to populations directly, and working with local health workers, the members of this breakout session provided several recommendations for healthcare providers and researchers to establish trust with diverse populations.
The workshop concluded with closing remarks by Dr. Richard Hodes, the director of the NIA. He stressed how the many factors discussed in this workshop influence and contribute to health disparities. Furthermore, he explained that the workshop highlighted challenges in understanding the disparities that underlie OA. He concluded by expressing commitment from the NIA, NIAMS, and NIMHD to continue to identify gaps and priorities in OA moving forward.