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Black, Asian, and Hispanic members of the U.S. Armed Forces were far less likely than their white comrades to undergo knee replacement surgeries after being diagnosed with osteoarthritis (OA), military researchers found.

In an analysis of some 21,000 individuals treated in the U.S. military health system -- in which all personnel are supposedly treated equally, regardless of rank or other factors -- rates of knee arthroplasty for non-white personnel were half to two-thirds that seen for white personnel, according to Krista B. Highland, PhD, of the Uniformed Services University in Bethesda, Maryland, and colleagues, .

After adjusting for covariates, incidence rate ratios for knee replacement relative to white patients were as follows:

• Black: 0.52, 95% CI 0.46-0.59
• Latino: 0.66, 95% CI 0.52-0.85
• Asian/Pacific Islander: 0.58, 95% CI 0.45-0.74

The findings indicate "that racialized inequities in knee arthroplasty persisted in the U.S. Military Health System, even when accounting for other care receipt," the researchers wrote. "System-wide efforts and resources are needed to mitigate inequities and improve osteoarthritis care."

Highland and colleagues noted that similar disparities in arthroplasty have been found rampant elsewhere, including the Veterans Affairs health system, as well as in Medicare and Medicaid. While the military system is typically considered the most equitable, treatment of OA (especially in its later stages) hasn't been studied there previously.

People receiving care in the Military Health System include active-duty service members, retirees, and their spouses and children. Care may be delivered in military clinics and hospitals and also through the TRICARE system. Highland's group examined records of all such patients diagnosed with OA from January 2016 through January 2020, with 3 years of follow-up after diagnosis. Patients whose records didn't extend 1 year prior to diagnosis were excluded.

Covariates of interest included several care-level factors such as numbers of physical therapy visits both prior to and following OA diagnosis, plus whether or not patients were prescribed opioids or other pain relievers. Quantities of opioids prescribed were also tracked. Claims data indicative of other illnesses before OA diagnosis were used to develop Charlson Comorbidity scores for each patient.

Just under 12,000 of the included patients were white. About 6,700 were classified as Black, 1,400 as Asian/Pacific Islander, and 1,700 as Latino. Mean age was 52 overall, although Latino patients were somewhat younger, averaging 46 years. Some 40% of the full sample and most racial-ethnic groups were on active duty; this was true for 62% of Latinos, as expected from their younger mean age. Most patients had a Charlson Comorbidity Index of 1.

Knee replacements were performed in 7% of the overall sample. Among the racial-ethnic groups, the rate varied from 4% for Latinos to 10% for white patients. The median time to have the procedure was 379 days after diagnosis, which varied little among racial-ethnic groups (except, again, for Latinos, for whom the median was 485 days). Very few people in any group had physical therapy documented in their records prior to OA diagnosis, and afterward, the median number of sessions was just one.

Why the apparent discrimination? The study data provided no specific clues, and Highland and colleagues made no accusations of overt racism. Instead, they cited points of context in the wider U.S. healthcare environment: for example, Black patients tend not to seek medical care for knee pain until OA is relatively advanced. As well, the researchers noted that Black and Hispanic patients outside the military are not offered knee arthroplasty as often as white patients, perhaps because "candidacy criteria" for surgery include having an accessible living space and a full-time caregiver after discharge, as well as an upper limit on body mass index -- all of which are "associated with and resultant of systemic racism," the group wrote. These factors may apply within the military system, where healthcare personnel may also carry the same unconscious biases as those in other settings.

"While mitigating the impact of structural, institutional, and personally-mediated racism requires intentional evaluation and action at higher echelons of healthcare system influence and leadership," the researchers continued, "such work may be stymied by the dearth of transparent health equity-monitoring, personnel resources, and explicit leadership prioritization to cultivate change."

Limitations to the study included a lack of data on some factors that might influence decisions to offer and receive arthroplasty, such as OA grades at diagnosis or use of imaging or educational interventions. Also, the study relied on administrative data, which may contain errors.

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