Hospital for Special Surgery and Weill Cornell Medicine, New York, New York.
Hospital for Special Surgery, New York, New York.
Arthritis Care Res (Hoboken). 2018 Jun;70(6):884-891. doi: 10.1002/acr.23442. Epub 2018 Apr 12.
Total knee arthroplasty (TKA) outcomes are worse for patients from poor neighborhoods, but whether education mitigates the effect of poverty is not known. We assessed the interaction between education and poverty on 2-year Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function.
Patient-level variables from an institutional registry were linked to US Census Bureau data (census tract [CT] level). Statistical models including patient and CT-level variables were constructed within multilevel frameworks. Linear mixed-effects models with separate random intercepts for each CT were used to assess the interaction between education and poverty at the individual and community level on WOMAC scores.
Of 3,970 TKA patients, 2,438 (61%) had some college or more. Having no college was associated with worse pain and function at baseline and 2 years (P = 0.0001). Living in a poor neighborhood (>20% below poverty line) was associated with worse 2-year pain (P = 0.02) and function (P = 0.006). 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 (83.4% versus 75.7%; P < 0.0001); in wealthy communities, college was associated with a 1-point difference in pain. Function was similar.
In poor communities, those without college attain 2-year WOMAC scores that are 10 points worse than those with some college; education has no impact on TKA outcomes in wealthy communities. How education protects those in impoverished communities warrants further study.
来自贫困社区的患者接受全膝关节置换术（TKA）的效果较差，但教育是否能减轻贫困的影响尚不清楚。我们评估了教育和贫困对 2 年 Western Ontario 和 McMaster 大学骨关节炎指数（WOMAC）疼痛和功能的交互作用。
从机构注册处获取患者水平变量，并与美国人口普查局数据（普查区 [CT] 水平）相关联。在多层次框架内构建包含患者和 CT 水平变量的统计模型。使用具有每个 CT 单独随机截距的线性混合效应模型来评估个人和社区层面的教育和贫困对 WOMAC 评分的交互作用。
在 3970 例 TKA 患者中，有 2438 例（61%）接受过一些大学或更高程度的教育。没有大学学历的患者在基线和 2 年时的疼痛和功能均较差（P=0.0001）。生活在贫困社区（>20%的人口生活在贫困线以下）与 2 年时的疼痛（P=0.02）和功能（P=0.006）较差有关。个人教育和社区贫困与 2 年时 WOMAC 评分之间存在强烈的相互作用。生活在贫困社区且没有大学学历的患者的疼痛评分比接受过一些大学教育的患者差约 10 分（83.4%比 75.7%；P<0.0001）；在富裕社区，接受过大学教育的患者的疼痛评分仅相差 1 分。功能情况相似。
在贫困社区，没有大学学历的患者的 2 年 WOMAC 评分比接受过一些大学教育的患者差 10 分；在富裕社区，教育对 TKA 结果没有影响。需要进一步研究教育如何保护那些生活在贫困社区的人。
