The first large-scale study of ethnicity and joint replacement in the UK, using data from the National Joint Registry, showed that ethnic minorities are less likely to receive hip or knee joint replacements. OPN meets lead authors Professor Ade Adebajo and Professor Ashley Blom to discuss the key findings
Q: Tell us a little about your background and education within orthopaedics?
AA: My time is split between clinical work, research, education and administration. Clinically, I very much enjoy seeing and looking after patients. I feel that it is so important to help improve patients’ quality of life. I believe that ‘adding life to years’ is as important as ‘adding years to life’.
In addition to being an educational supervisor for junior doctors, I am involved in a range of activities with medical students, especially in my role as Associate Director of Teaching for the University of Sheffield Medical School. My main research is in international musculoskeletal health and health–service research, which both overlap greatly. In particular, I see education as an important health intervention, effective at an individual level for patients and healthcare professionals, but also on a community and even national level.
I have been fortunate to combine my clinical interests with projects that have often either been funded directly by Arthritis Research UK or worked on other UK-funded projects, such as this particular in-depth study with the National Joint Registry.
Q: Could you tell us more about your study on ethnicity and joint replacement?
AA: In the UK and USA existing research has shown that people in the most deprived groups are less likely to receive joint replacements than those of higher socio-economic status and at least one US study has suggested that there may also be racial disparities.
This is the first large-scale study to confirm that in the UK, as in other countries, ethnic minorities are less likely to receive hip or knee joint replacements than the white majority.
Q: What factors did you consider in your research?
AA: Despite a healthcare system that is free at the point of delivery, ethnic minorities may not always get care equitable to that of white patients in England. We examined whether ethnic differences exist in joint replacement rates and surgical practice in England.
This study was able to use the huge amount of data available recorded in the NJR – the largest joint replacement registry in the world. The findings provide quantitative analysis and show that statistically there is a variation in observed numbers compared to expected numbers of patients having a primary hip or knee joint replacement by ethnicity.
Going forward, further research using qualitative information is needed to understand the importance of each possible reason as to why there are such differences in the rates of joint replacement in different ethnic groups, and in the types of implant and fixation used. Our research demonstrates the value for research and clinical practice of the NJR as a large data source.
One possible explanation could be patient willingness to undergo surgery among the different ethnic groups examined. This is often shaped by cultural factors, doctor-patient communication, and even patient trust in the healthcare system. But this needs confirmation and further investigation.
Q: Did gender play a part too?
AA: Yes, the published paper shows the observed numbers compared to expected numbers of patients having a primary hip or knee joint replacement by ethnicity and stratified by gender.
Q: Was the type of implant important? If so, why?
AB: Yes, the study observed that the hospital in which a patient is operated on is a major determinant of the differences in hip replacement fixation method. Patients from an ethnic minority background are surprisingly more likely to receive the more expensive uncemented hip prosthesis compared to white patients. This can be partially explained by the fact that ethnic minority groups are more likely to have their joint replacement in large, urban hospitals that tend to serve a greater proportion of ethnic minority patients and are high users of these more expensive prostheses.
Q: How can the results influence decisions on future knee replacement surgery?
AA: One significant finding for knee replacement was that there were markedly fewer than expected procedures carried out on men compared to women. This may suggest there is a mismatch between when joint replacement needs to be done and when patients want it done.
Variations in the prevalence of disease – particularly osteoarthritis, the dominant condition leading to hip or knee joint replacement – and differences in willingness to undergo surgery among the different ethnic groups may be possible explanations for the differences observed.
These results suggest further qualitative information is needed to better understand the importance of the findings in relation to knee replacement surgery.
Q: Where next with your research?
AA: There is a strong case to be made for improving health literacy among ethnic minorities to improve the uptake in joint replacement. Doing so would remove barriers, helping to ensure that the most deprived groups are as likely to receive joint replacements by improving doctor/patient communication and patient trust in the healthcare system.
Ade Adebajo is professor of rheumatology and health service research at the University of Sheffield, a consultant physician in rheumatology and clinical director for research and development at Barnsley Hospital NHS Foundation Trust.
Professor Ashley Blom, from the University of Bristol, led the team that undertook the study on behalf of the National Joint Registry.