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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 25 of 27 Research Studies DisplayedFranklin PD, Bond CP, Rothrock NE
Strategies for effective implementation of patient-reported outcome measures in arthroplasty practice.
This study’s goal was to synthesize patient-reported outcome measure (PROM) implementation strategies that are successfully used by hundreds of arthroplasty surgeons and early PROM-adopter clinical systems. The authors developed guidelines to inform clinical care, drive quality-improvement activities, and support reporting for payer-sponsored incentives. They also outlined future research that is needed to define methods for optimal patient engagement, technology infrastructure, and operational systems to seamlessly integrate PROM collection in clinical care.
AHRQ-funded; HS018910.
Citation: Franklin PD, Bond CP, Rothrock NE .
Strategies for effective implementation of patient-reported outcome measures in arthroplasty practice.
J Bone Joint Surg Am 2021 Dec 15;103(24):e97. doi: 10.2106/jbjs.20.02072..
Keywords: Patient-Centered Outcomes Research, Orthopedics, Quality Improvement, Quality of Care, Evidence-Based Practice, Implementation, Outcomes
Kittelson AJ, Loyd BJ, Graber J
Examination of exclusion criteria in total knee arthroplasty rehabilitation trials: influence on the application of evidence in day-to-day practice.
This study investigated whether total knee arthroplasty (TKA) patients seen in routine practice who meet common exclusion criteria in clinical trials recover differently compared to research-eligible patients. Postoperative functional outcomes were compared using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Timed Up and Go (TUG). A total of 2,528 participants from 27 trials were compared to 474 patients from the clinical dataset. Research participants were older, with lower BMI than patients in the clinical dataset. There were no differences observed in functional recovery rate between groups, except for patients with diabetes whose TUG recovered more slowly than “eligible” patients.
AHRQ-funded; HS024316.
Citation: Kittelson AJ, Loyd BJ, Graber J .
Examination of exclusion criteria in total knee arthroplasty rehabilitation trials: influence on the application of evidence in day-to-day practice.
J Eval Clin Pract 2021 Dec;27(6):1335-42. doi: 10.1111/jep.13564..
Keywords: Orthopedics, Surgery, Rehabilitation, Patient-Centered Outcomes Research, Evidence-Based Practice, Outcomes
Brown TT, Hurley VB, Rodriguez HP
Association of patient engagement strategies with utilisation and spending for musculoskeletal problems in the USA: a cross-sectional analysis of Medicare patients and physician practices.
This cross-sectional study assessed the association of physician practice-level adoption of patient engagement strategies (PES), such as shared decision-making and motivational interviewing, with utilization and spending. The cohort included primary and secondary patients in 2190 practices who receiving treatment for hip (39,336), knee (48,362), and lower-back (67,940) issues who were Medicare beneficiaries that were matched to the 2017-2018 National Survey of Healthcare Organizations and Systems. Outcome measures were total knee replacement (TKR), total hip replacement (THR), 1-2 level posterior lumbar fusion (LF), total annual spending, and components of total annual spending. Spending was significantly lower in some categories for practices with relatively higher PES adoption, but did not differ for other practices. The odds of receiving THR were higher in independent practices for patients attributed to practices with moderate PES compared to patients in practices with low PES.
AHRQ-funded; HS024075.
Citation: Brown TT, Hurley VB, Rodriguez HP .
Association of patient engagement strategies with utilisation and spending for musculoskeletal problems in the USA: a cross-sectional analysis of Medicare patients and physician practices.
BMJ Open 2021 Nov 26;11(11):e053121. doi: 10.1136/bmjopen-2021-053121..
Keywords: Patient and Family Engagement, Healthcare Utilization, Healthcare Costs, Arthritis, Orthopedics
Whitebird RR, Solberg LI, Ziegenfuss JY
Personalized outcomes for hip and knee replacement: the patients point of view.
Patient reported outcome measures (PROMs) are increasingly being incorporated into clinical and surgical care for assessing outcomes. This study examined outcomes important to patients in their decision to have hip or knee replacement surgery, their perspectives on PROMs and shared decision-making, and factors they considered important for postoperative care.
AHRQ-funded; HS025618.
Citation: Whitebird RR, Solberg LI, Ziegenfuss JY .
Personalized outcomes for hip and knee replacement: the patients point of view.
J Patient Rep Outcomes 2021 Nov 4;5(1):116. doi: 10.1186/s41687-021-00393-z..
Keywords: Orthopedics, Surgery, Patient-Centered Outcomes Research, Patient Experience, Decision Making
Halawi MJ, Gronbeck C, Metersky ML
AHRQ Author: Eldridge N
Time trends in patient characteristics and in-hospital adverse events for primary total knee arthroplasty in the United States: 2010-2017.
This study looked at trends in patient characteristics and in-hospital adverse events (AEs) for primary total knee arthroplasty (TKA) from 2010 to 2017. A total of 14,057 primary TKAs captured by the Medicare Patient Safety Monitoring System was retrospectively reviewed. Risk factors that increased included obesity prevalence, tobacco smoking, and renal disease. There were reductions in coronary artery disease and chronic warfarin use. Inpatient AEs decreased from 4.9% to 2.5%, primarily driven by reductions in anticoagulant-associated AEs, including major bleeding and hematomas, catheter-associated urinary tract infections, pressure ulcers, and venous thromboembolism.
AHRQ-authored; AHRQ-funded; 290201800005C.
Citation: Halawi MJ, Gronbeck C, Metersky ML .
Time trends in patient characteristics and in-hospital adverse events for primary total knee arthroplasty in the United States: 2010-2017.
Arthroplast Today 2021 Oct;11:157-62. doi: 10.1016/j.artd.2021.08.010..
Keywords: Surgery, Orthopedics, Adverse Events, Risk
Whitebird RR, Solberg LI
What's important: postoperative care planning. recognizing the central role of pets in many patients' lives.
Pets are important in many of our lives, and so they are important during the recovery period following events like hip or knee surgery. This study was born from a reflection on the question of pet ownership as the investigators studied outcomes that patients desired from orthopaedic surgery and factors in their lives that they identified as important to their aftercare planning.
AHRQ-funded; HS025618.
Citation: Whitebird RR, Solberg LI .
What's important: postoperative care planning. recognizing the central role of pets in many patients' lives.
J Bone Joint Surg Am 2021 Sep 1;103(17):1663-64. doi: 10.2106/jbjs.21.00099..
Keywords: Surgery, Orthopedics
Liao JM, Gupta A, Zhao Y
Association between hospital voluntary participation, mandatory participation, or nonparticipation in bundled payments and Medicare episodic spending for hip and knee replacements.
The purpose of this study was to examine and compare 2011-2017 spending for hip and joint replacements between hospitals with voluntary participation, mandatory participation and nonparticipation in the Medicare Bundled Payments for Care Improvement program.
Citation: Liao JM, Gupta A, Zhao Y .
Association between hospital voluntary participation, mandatory participation, or nonparticipation in bundled payments and Medicare episodic spending for hip and knee replacements.
JAMA 2021 Aug 3;326(5):438-40. doi: 10.1001/jama.2021.10046..
Keywords: Medicare, Hospitals, Payment, Surgery, Orthopedics, Healthcare Costs
Kim C, Colborn KL, van Buuren S
Neighbors-based prediction of physical function after total knee arthroplasty.
The purpose of this study was to develop and test personalized predictions for functional recovery after Total Knee Arthroplasty (TKA) surgery, using a novel neighbors-based prediction approach. Findings showed that predictions were well-calibrated in out-of-sample testing. These predictions have the potential to inform care decisions both prior to and following TKA surgery.
AHRQ-funded; HS025692; HS024316.
Citation: Kim C, Colborn KL, van Buuren S .
Neighbors-based prediction of physical function after total knee arthroplasty.
Sci Rep 2021 Aug 18;11(1):16719. doi: 10.1038/s41598-021-94838-6..
Keywords: Orthopedics, Surgery, Arthritis
Pritchard KT, Hong I, Goodwin JS
Association of social behaviors with community discharge in patients with total hip and knee replacement.
The objective of this retrospective cohort study was to understand the association between social determinants of health and community discharge after elective total joint arthroplasty. Social determinants of health are associated with odds of community discharge after total hip and knee joint arthroplasty. The investigators concluded that their findings demonstrated the value of using electronic health record data to analyze more granular patient factors associated with patient discharge location after total joint arthroplasty. Although bundled payment is increasing community discharge rates, post-acute care facilities.
AHRQ-funded; HS026133.
Citation: Pritchard KT, Hong I, Goodwin JS .
Association of social behaviors with community discharge in patients with total hip and knee replacement.
J Am Med Dir Assoc 2021 Aug;22(8):1735-43.e3. doi: 10.1016/j.jamda.2020.08.021..
Keywords: Orthopedics, Surgery, Hospital Discharge
Pritchard KT, Baillargeon J, Raji Ma
Association of occupational and physical therapy with duration of prescription opioid use after hip or knee arthroplasty: a retrospective cohort study of Medicare enrollees.
The purpose of this study was to establish whether non-pharmacological interventions, such as occupational and physical therapy, were associated with a shorter duration of prescription opioid use after hip or knee arthroplasty. The investigators concluded that occupational and physical therapy with home health were associated with a shorter duration of prescription opioid use after hip and knee arthroplasty.
AHRQ-funded; HS026133.
Citation: Pritchard KT, Baillargeon J, Raji Ma .
Association of occupational and physical therapy with duration of prescription opioid use after hip or knee arthroplasty: a retrospective cohort study of Medicare enrollees.
Arch Phys Med Rehabil 2021 Jul;102(7):1257-66. doi: 10.1016/j.apmr.2021.01.086..
Keywords: Orthopedics, Surgery, Opioids, Pain, Practice Patterns
Long S, Thomas GW, Karam MD
Surgical skill can be objectively measured from fluoroscopic images using a novel image-based Decision Error Analysis (IDEA) score.
This study introduces and evaluates a novel Image-based Decision Error Analysis (IDEA) score that captures performance during fluoroscopically assisted wire navigation. Findings showed that the fluoroscopic images obtained in the course of placing a guide wire contained a rich amount of information related to surgical skill. The IDEA scoring provided a basis for evaluating the competence of a resident. The score can be used to assess skill at key timepoints throughout residency, such as when rotating onto/off of a new surgical service and before performing certain procedures in the operating room, or as a tool for debriefing/providing feedback after a procedure is completed.
AHRQ-funded; HS022077; HS025353.
Citation: Long S, Thomas GW, Karam MD .
Surgical skill can be objectively measured from fluoroscopic images using a novel image-based Decision Error Analysis (IDEA) score.
Clin Orthop Relat Res 2021 Jun;479(6):1386-94. doi: 10.1097/corr.0000000000001623..
Keywords: Orthopedics, Surgery, Decision Making, Medical Errors, Adverse Events, Imaging
Dy CJ, Salter A, Barker A
Increased utilization of total joint arthroplasty after Medicaid expansion.
This study examined prior analyses that greater utilization of total hip arthroplasty (THA) and total knee arthroplasty (TKA) was to be expected after Medicaid expansion in 2014. Using 2012-2015 data from the HCUP Database, 9 expansion states (Arkansas, Arizona, Colorado, Iowa, Massachusetts, Maryland, Nevada, New York, and Vermont) were compared to 2 states that did not expand Medicaid (Florida and Missouri). After adjusting for community characteristics, THA and TKA increased 15% in 2014 and 23% in 2015 within expansion states compared to 2013. In non-expansion states, compared to 2013, there were significant decreases of 18% in 2014 and 11% in 2015.
AHRQ-funded; HS019455.
Citation: Dy CJ, Salter A, Barker A .
Increased utilization of total joint arthroplasty after Medicaid expansion.
J Bone Joint Surg Am 2021 Mar 17;103(6):524-31. doi: 10.2106/jbjs.20.00303..
Keywords: Healthcare Cost and Utilization Project (HCUP), Medicaid, Orthopedics, Surgery, Healthcare Utilization, Access to Care
Griesemer I, Hausmann LR, Arbeeva L
Discrimination experiences and depressive symptoms among African Americans with osteoarthritis enrolled in a pain coping skills training randomized controlled trial.
This study evaluated the interaction between discrimination experiences and depressive symptoms among African Americans with osteoarthritis enrolled in a pain coping skills training (PCST) randomized controlled trial. The authors evaluated the interactions for 164 participants in linear regression models predicting depressive symptoms. There was a significant interaction between personal discrimination and experimental condition on depressive symptoms. Discrimination was associated with depressive symptoms among the control group but not among those who received PCST.
AHRQ-funded; HS000032.
Citation: Griesemer I, Hausmann LR, Arbeeva L .
Discrimination experiences and depressive symptoms among African Americans with osteoarthritis enrolled in a pain coping skills training randomized controlled trial.
J Health Care Poor Underserved 2021;32(1):145-55. doi: 10.1353/hpu.2021.0014..
Keywords: Racial and Ethnic Minorities, Pain, Arthritis, Orthopedics, Patient Experience, Depression
Lopez-Olivo MA, des Bordes JK, Lin H
A randomized controlled trial comparing two self-administered educational strategies for patients with knee osteoarthritis.
The authors conducted a randomized clinical trial in patients with knee osteoarthritis to assess the efficacy of providing a video for entertainment education, in combination with two booklets, compared with providing the booklets alone. They found that, although both education strategies were associated with improved knowledge and reduced decisional conflict at 6 months, receiving the video + booklets in combination, compared with receiving the booklets alone, proved to be more effective in changing behaviors and appeared to have some advantages for Spanish speakers and those who were less educated.
AHRQ-funded; HS019354.
Citation: Lopez-Olivo MA, des Bordes JK, Lin H .
A randomized controlled trial comparing two self-administered educational strategies for patients with knee osteoarthritis.
ACR Open Rheumatol 2021 Mar;3(3):185-95. doi: 10.1002/acr2.11222..
Keywords: Arthritis, Orthopedics, Education: Patient and Caregiver, Patient Self-Management, Patient Adherence/Compliance, Decision Making, Health Promotion
Agarwal AK, Lee D, Ali Z
Patient-reported opioid consumption and pain intensity after common orthopedic and urologic surgical procedures with use of an automated text messaging system.
This prospective study looked at the number of opioid tablets taken compared to the number prescribed after orthopedic and urologic surgery at a large urban academic health center in Pennsylvania from May to December 2019 with the use of an automated text messaging system. Of the 919 study participants, 80.7% (742) underwent orthopedic procedures and 19.2% underwent urologic procedures. Among those who underwent orthopedic procedures, 384 were women, 491 were White, and the median age was 48 years; with almost 70% outpatient procedures. Among those who underwent urologic procedures, 84.8% were men, 80.7% were White, and the median age was 56 years; 62% had an outpatient procedure. Orthopedic patients were prescribed an average of 20 tablets and urologic patients 7 tablets. The majority of patients (64.1%) used less than half of the amount prescribed, and 256 orthopedic and 77 urologic patients did not use any opioids. The findings suggest that clinicians can tailor prescriptions to limit excess quantities of prescribed opioids.
AHRQ-funded; HS026372.
Citation: Agarwal AK, Lee D, Ali Z .
Patient-reported opioid consumption and pain intensity after common orthopedic and urologic surgical procedures with use of an automated text messaging system.
JAMA Netw Open 2021 Mar;4(3):e213243. doi: 10.1001/jamanetworkopen.2021.3243..
Keywords: Opioids, Medication, Pain, Orthopedics, Surgery
O'Hara NN, Slobogean GP, Klazinga NS
Analysis of patient income in the 5 years following a fracture treated surgically.
Investigators characterized the association between orthopedic injury and patient income using state tax records. They found that, in this cohort study of patients surgically treated for an orthopedic fracture at a US academic trauma center, fractures were associated with substantial individual and household income loss up to 5 years after injury, and 1 in 5 patients sustained catastrophic income loss in the 2 years after fracture. Gains in Social Security benefits offset less than 10% of annual income losses.
AHRQ-funded; HS027218.
Citation: O'Hara NN, Slobogean GP, Klazinga NS .
Analysis of patient income in the 5 years following a fracture treated surgically.
JAMA Netw Open 2021 Feb;4(2):e2034898. doi: 10.1001/jamanetworkopen.2020.34898..
Keywords: Injuries and Wounds, Surgery, Orthopedics
Snell DL, Dunn JA, Jerram KAS
AHRQ Author: Hsieh CJ
Associations between comorbidity and quality of life outcomes after total joint replacement.
In this study, a cross-sectional, questionnaire-based national survey, the authors examined associations between self-reported and clinician-assessed comorbidity and quality of life (QOL) outcomes after hip and knee replacement. The investigators concluded that the results showed that general QOL outcomes following hip and knee joint replacement, while typically high, were associated with comorbidity burden and BMI.
AHRQ-authored.
Citation: Snell DL, Dunn JA, Jerram KAS .
Associations between comorbidity and quality of life outcomes after total joint replacement.
Qual Life Res 2021 Jan;30(1):137-44. doi: 10.1007/s11136-020-02610-6..
Keywords: Quality of Life, Surgery, Orthopedics, Outcomes
Lamplot JD, Bansal A, Nguyen JT
Risk of subsequent joint arthroplasty in contralateral or different joint after index shoulder, hip, or knee arthroplasty: association with index joint, demographics, and patient-specific factors.
The purpose of this study using HCUP data was to determine how demographic and other patient-specific factors are associated with the risk of subsequent joint replacement in the contralateral or a different joint following an index joint replacement for osteoarthritis. Results showed a relatively high risk of subsequent replacement of the contralateral joint and a relatively low risk of subsequent replacement of a different joint within 5 to 8 years after an index total hip arthroplasty, total knee arthroplasty, or total shoulder arthroplasty. Obesity was associated with a higher risk of subsequent replacement of the contralateral joint or a different joint.
AHRQ-funded; HS019455.
Citation: Lamplot JD, Bansal A, Nguyen JT .
Risk of subsequent joint arthroplasty in contralateral or different joint after index shoulder, hip, or knee arthroplasty: association with index joint, demographics, and patient-specific factors.
J Bone Joint Surg Am 2018 Oct 17;100(20):1750-56. doi: 10.2106/jbjs.17.00948..
Keywords: Arthritis, Healthcare Cost and Utilization Project (HCUP), Risk, Surgery, Orthopedics, Healthcare Utilization
Hilliard PE, Waljee J, Moser S
Prevalence of preoperative opioid use and characteristics associated with opioid use among patients presenting for surgery.
Researchers assessed the prevalence of preoperative opioid use and the characteristics of patients in a broadly representative surgical cohort. They found that patients undergoing lower extremity procedures were most likely to report preoperative opioid use, with 1 in 4 of all patients presenting for surgery reporting such use. They concluded that the data provided important insights into this population and would appear to help guide future preoperative optimization and perioperative opioid-weaning interventions.
AHRQ-funded; HS023313.
Citation: Hilliard PE, Waljee J, Moser S .
Prevalence of preoperative opioid use and characteristics associated with opioid use among patients presenting for surgery.
JAMA Surg 2018 Oct;153(10):929-37. doi: 10.1001/jamasurg.2018.2102..
Keywords: Opioids, Surgery, Pain, Medication, Healthcare Utilization, Orthopedics
Mittal M, Wang CE, Goben AH
Proprietary management and higher readmission rates: a correlation.
This study examined readmission rates of patients for six diseases including acute myocardial infarction, heart failure, coronary artery bypass graft, pneumonia, COPD, and total hip or total knee arthroplasty from the Center for Medicare and Medicaid Readmissions Reduction Production (HRRP) for 2012 to 2015. The type of hospital ownership was the variable that was being studied. There were statistically higher readmission rates in proprietary (for profit) hospitals compared to government and non-profit hospitals. This was true regardless of their location.
AHRQ-funded; HS024679.
Citation: Mittal M, Wang CE, Goben AH .
Proprietary management and higher readmission rates: a correlation.
PLoS One 2018 Sep 18;13(9):e0204272. doi: 10.1371/journal.pone.0204272..
Keywords: Cardiovascular Conditions, Hospital Readmissions, Hospitals, Orthopedics, Respiratory Conditions
Pellegrini CA, Chang RW, Dunlop DD
Comparison of a Patient-Centered Weight Loss Program starting before versus after knee replacement: a pilot study.
This article reports the results of a randomized pilot study that assessed changes in weight during a Patient Centered Weight Loss Program (PACE) initiated either before or after knee replacement. The feasibility of recruiting and retaining participants over 26 weeks was also examined. Recruitment outreach was extended to patients scheduled for knee replacement. Sixteen participants were randomly assigned to a 14-session weight loss program that started either at least 6 weeks before surgery or at 12 weeks following surgery. The authors conclude that behavioral intervention is challenging but feasible in a knee replacement population. Preliminary evidence suggests that initiating a program 12 weeks after surgery produces greater weight losses at 26 weeks when compared to a program that begins before knee replacement.
AHRQ-funded; HS023011.
Citation: Pellegrini CA, Chang RW, Dunlop DD .
Comparison of a Patient-Centered Weight Loss Program starting before versus after knee replacement: a pilot study.
Obes Res Clin Pract 2018 Sep - Oct;12(5):472-78. doi: 10.1016/j.orcp.2018.06.009..
Keywords: Orthopedics, Patient-Centered Healthcare, Patient-Centered Outcomes Research, Obesity: Weight Management, Surgery, Obesity, Outcomes
Urish KL, Qin Y, Li BY
Predictors and cost of readmission in total knee arthroplasty.
The Comprehensive Care for Joint Replacement bundle was created to decrease total knee arthroplasty (TKA) cost. To help accomplish this, there is a focus on reducing TKA readmissions. The study’s authors used the Nationwide Readmission Database to examine national readmission rates, predictors of readmission, and associated readmission costs for elective TKA procedures.
AHRQ-funded; HS018726.
Citation: Urish KL, Qin Y, Li BY .
Predictors and cost of readmission in total knee arthroplasty.
J Arthroplasty 2018 Sep;33(9):2759-63. doi: 10.1016/j.arth.2018.04.008..
Keywords: Arthritis, Healthcare Costs, Healthcare Cost and Utilization Project (HCUP), Hospital Readmissions, Orthopedics
Rosenberg RE, Abzug JM, Rappaport DI
Collaborations with pediatric hospitalists: national surveys of pediatric surgeons and orthopedic surgeons.
In this study, to understand characteristics of pediatric hospitalist (PH) involvement in the care of children admitted to surgical services and explore surgeons' perspectives of PH effectiveness, the investigators conducted a cross-sectional, web-based survey of pediatric surgical (PS) and pediatric orthopedic subspecialists (OS) from professional organizations.
AHRQ-funded; HS022198.
Citation: Rosenberg RE, Abzug JM, Rappaport DI .
Collaborations with pediatric hospitalists: national surveys of pediatric surgeons and orthopedic surgeons.
J Hosp Med 2018 Aug;13(8):566-69. doi: 10.12788/jhm.2921..
Keywords: Children/Adolescents, Orthopedics, Surgery, Hospitals, Inpatient Care
Pellegrini CA, Ledford G, Chang RW
Understanding barriers and facilitators to healthy eating and physical activity from patients either before and after knee arthroplasty.
The researchers sought to identify patient-reported barriers and facilitators to healthy eating and physical activity among patients before or after knee arthroplasty. They found that identifying specific eating and activity barriers and facilitators provides critical insight from the patient perspective, which will aid in developing weight management programs during rehabilitation for knee arthroplasty patients.
AHRQ-funded; HS023011.
Citation: Pellegrini CA, Ledford G, Chang RW .
Understanding barriers and facilitators to healthy eating and physical activity from patients either before and after knee arthroplasty.
Disabil Rehabil 2018 Aug;40(17):2004-10. doi: 10.1080/09638288.2017.1323026.
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Keywords: Nutrition, Obesity, Orthopedics, Surgery
Goodman SM, Mandi LA, Mehta B
Does education level mitigate the effect of poverty on total knee arthroplasty outcomes?
The authors assessed the interaction between education and poverty on 2-year Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function. They found that having no college was associated with worse pain and function at baseline and 2 years and that living in a poor neighborhood was associated with worse 2-year pain and function. There was a strong interaction between individual education and community poverty with WOMAC scores at 2 years. Patients without college living in poor communities had pain scores that were ~10 points worse than those with some college; in wealthy communities, college was associated with a 1-point difference in pain. Function was similar. The authors recommended further study on how education protects those in impoverished communities.
AHRQ-funded; HS016075.
Citation: Goodman SM, Mandi LA, Mehta B .
Does education level mitigate the effect of poverty on total knee arthroplasty outcomes?
Arthritis Care Res 2018 Jun;70(6):884-91. doi: 10.1002/acr.23442..
Keywords: Arthritis, Education, Low-Income, Orthopedics, Outcomes, Patient-Centered Outcomes Research, Social Determinants of Health