Original article
Self-assessed global quality of life: A comparison between African-American and white older patients with arthritis

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Abstract

Quality of life (QOL) perceptions influence patient decisions and preferences for care and, more importantly, physicians may render recommendations based on their impressions of the patient's QOL. QOL is perceived differently by different ethnic groups. This may have implications for understanding ethnic disparities in medical procedure utilization such as joint replacement for osteoarthritis. In a study of 596 elderly male patients with moderate to severe symptomatic knee/hip osteoarthritis, we examined how African-American and white patients rate their overall QOL. We adjusted their responses for important demographic, clinical, and psychosocial potential confounders. African-American (44%) and white (56%) patients in this study were comparable, except that African-Americans reported lower socioeconomic status compared with whites. After adjusting for all other study covariates, African-American ethnicity (B= -0.121, P = 0.004) was negatively correlated with overall QOL ratings. How ethnic variations in perceptions of QOL impact observed ethnic disparity in the utilization of joint replacement therapy needs further investigation.

Introduction

In the study and management of older patients with chronic disease, quality of life (QOL) is often a key outcome variable. [1] This is in part because it better reflects the impact of chronic disease on the patient than survival alone. Furthermore, QOL [2] has been shown to predict health care outcomes such as mortality and medical services utilization 3, 4, 5.

QOL is defined and measured in various ways including health status, health-related QOL, and overall QOL. In all cases, the purpose is to focus on how patients perceive and react to health-related and non-health-related aspects of their lives. Some have suggested that QOL is best measured when both health-related matters, such as physical well-being or mental well-being, and non-health-related matters, such as social environment, financial issues, and cultural factors, are taken into account [6]. After all, when it comes to QOL, many patients may not be able to distinguish between health-related and non-health-related matters.

When defined and measured in such a broad fashion, QOL may have implications for understanding patient perceptions of illness as well as the reasons behind the widely documented ethnic disparities in health care utilization and outcomes. These findings are most relevant for the management of chronic conditions such as osteoarthritis of the knee or hip; in such cases, QOL may be a factor in determining when and why patients seek care and whether physicians recommend intervention. There is a marked difference, for instance, between African-Americans and whites in the utilization of joint replacement therapy for knee/hip osteoarthritis. White men are reported to be 3.3 to 5.1 times more likely than African-American men to undergo joint replacement. The ratio for women ranges from 1.5 to 2.0 7, 8, 9, 10. The reasons behind this disparity are not known. Differences in osteoarthritis prevalence do not explain it, as osteoarthritis is equally prevalent in all ethnic groups [11]. Access to care is also unlikely to explain all the differences, as disparities in medical procedure utilization have been documented both in the VA health system, where access is less of an issue, and in the private sector 7, 8, 10, 12, 13, 14. After adjusting for disease/functional status, comorbidities, depression, and socioeconomic factors, if African-American patients with knee and/or hip osteoarthritis are more likely than their white counterparts to report higher QOL, it is reasonable to hypothesize that they would be less likely to seek joint replacement as an option—thus explaining in part the observed disparity in joint replacement utilization. This hypothesis is supported by the evidence showing that QOL perceptions influence patient decisions and preferences for care 15, 16. More importantly, physicians may render recommendations based on their impressions of the patient's QOL[17]. Before pursuing this hypothesis, however, it would be useful to demonstrate that African-American and white patients in a sample of potential candidates for joint replacement therapy rate their QOL differently.

With this in mind, we analyzed data collected in a study of older patients with moderate to severe symptomatic osteoarthritis of the knee and/or hip. We were specifically interested in comparing African-American and white patients with respect to their self-rated overall QOL. QOL was assessed using a single-item global quality of life question. Data on demographic, clinical, and psychosocial factors were also collected.

Section snippets

Patient population

Subjects were participants in the Department of Veterans Affairs-funded study on Ethnic/Cultural Variations in the Management of Osteoarthritis. Between May 1997 and March 2000, 1351 patients attending the primary care firms of the Louis Stokes Cleveland VA Medical Center in Cleveland, Ohio, were randomly approached by trained interviewers. Patients were initially asked a series of questions regarding the presence, duration, and severity of hip or knee pain. The following questions were taken

Baseline demographic information

Using field-tested questionnaires, interviewers gathered demographic information, such as age, educational level, employment status, annual household income, and marital status. Patients were asked to self-identify their ethnicity. Chart and VA clinical computer database abstractions provided information on medications, comorbidity, and health care utilization. All participants had hip or knee X rays to obtain radiographic evidence of osteoarthritis. Radiographic evaluation of the more

Baseline comparisons

Table 1 summarizes baseline clinical, demographic, and psychosocial characteristics of the comparison groups. The two groups were comparable with respect to age; severity of disease as measured by WOMAC index; Lequesne scale scores; Geriatric Depression Scores; and overall comorbidity as measured by the Charlson Comorbidity Index. African-American patients were more likely to report lower annual household income and were less likely than whites to be employed or married, or to have education

Discussion

In this study of 596 older male patients with chronic knee/hip pain, African-Americans were significantly less likely than whites to rate their overall quality of life as excellent or very good. This difference persisted after adjusting for important demographic, clinical, and psychosocial covariates, as well as the severity of the osteoarthritis.

Although this study compared African-American and white older patients with chronic knee/hip pain with respect to their perceptions of global QOL, the

Acknowledgements

This study was funded by the Health Services Research and Development Office of the Veterans Health Care System. Dr. Ibrahim is a recipient of a Health Services Research Career Development Award from this office.

The authors thank Kenneth Covinsky, MD, MPH, for his review of the manuscript and Barbara Juknialis, M.A., for her editorial assistance in the development of this manuscript.

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