Showing papers in "Journal of Health Care for the Poor and Underserved in 2013"

Barriers to health care among Asian immigrants in the United States: a traditional review.

Abstract: Asian immigrants in the U.S. are far less likely to have health insurance or use health care services than both U.S.-born Asians and non-Hispanic Whites. Furthermore, Asian immigrants who access the U.S. health care system are less likely than non-Hispanic Whites to receive high-quality services. This paper reviews four barriers faced by Asian immigrants to participating in the U.S. health care system fully: (1) linguistic discordance between providers and patients; (2) health-related beliefs and cultural incompetency of health systems; (3) issues related to accessing health services; and (4) discrimination in the health care system. Interventions to improve the health of Asian immigrants must address barriers experienced at multiple levels, including those that occur interpersonally and institutionally, as well as broader societal factors that affect health care access and quality.

The Problem of Late ART initiation in Sub-Saharan Africa: A Transient Aspect of Scale-up or a Long-term Phenomenon?

Abstract: Efforts to scale-up HIV care and treatment have been successful at initiating large numbers of patients onto antiretroviral therapy (ART), although persistent challenges remain to optimizing scale-up effectiveness in both resource-rich and resource-limited settings. Among the most important are very high rates of ART initiation in the advanced stages of HIV disease, which in turn drive morbidity, mortality, and onward transmission of HIV. With a focus on sub-Saharan Africa, this review article presents a conceptual framework for a broader discussion of the persistent problem of late ART initiation, including a need for more focus on the upstream precursors (late HIV diagnosis and late enrollment into HIV care) and their determinants. Without additional research and identification of multilevel interventions that successfully promote earlier initiation of ART, the problem of late ART initiation will persist, significantly undermining the long-term impact of HIV care scale-up on reducing mortality and controlling the HIV epidemic.

Incarceration, community health, and racial disparities.

Abstract: Several recent studies have shown that the racial disparities in U.S. mortality nearly disappear in prisons. We review the social determinants of the recent epidemic of incarceration, especially the war on drugs, and describe inmate morbidity and mortality within the context of U.S. health disparities. Incarceration provides an important public health opportunity to address health disparities by accessing a high-need, medically-underserved, largely non-White population, but it has also been associated with poor long-term health outcomes. Viewing incarceration within the context of community health and community life shows that the more equitable mortality rates among inmates are not evidence of the beneficial effects of incarceration so much as an indictment of disparities in the community at large. Because people of color are incarcerated far more frequently than Whites, the experience may ultimately exacerbate rather than mitigate health disparities.

Doctors and lawyers collaborating to HeLP children--outcomes from a successful partnership between professions

Abstract: Background . Clear associations exist between socioeconomic risks and health, and these risks are often amenable to legal interventions. Methods . This is a case study of an implementation of a medical-legal partnership (MLP) in three pediatric primary care centers that serve a predominantly high-risk population. Referral circumstances and outcomes over the first three years are described. Results . During the three-year study period, 1,808 MLP referrals were made for 1,614 patients by all levels of provider. Those referred were more likely to have asthma (p Conclusion. Successful MLP implementation enabled pediatric providers to address social determinants of health potentially improving health and reducing disparities.

Medical respite programs for homeless patients: a systematic review.

Abstract: Medical respite programs provide care to homeless patients who are too sick to be on the streets or in a traditional shelter, but not sick enough to warrant inpatient hospitalization. They are designed to improve the health of homeless patients while also decreasing costly hospital use. Although there is increasing interest in implementing respite programs, there has been no prior systematic review of their effectiveness. We conducted a comprehensive search for studies of medical respite program outcomes in multiple biomedical and sociological databases, and the grey literature. Thirteen articles met inclusion criteria. The articles were heterogeneous in methods, study quality, inclusion of a comparison group, and outcomes examined. Available evidence showed that medical respite programs reduced future hospital admissions, inpatient days, and hospital readmissions. They also resulted in improved housing outcomes. Results for emergency department use and costs were mixed but promising. Future research utilizing adequate comparison groups is needed.

The Prevalence of Trauma and Childhood Adversity in an Urban, Hospital-Based Violence Intervention Program

Abstract: Hospitals represent a promising locus for preventing recurrent interpersonal violence and its psychological sequella. We conducted a cross-sectional analysis to assess the prevalence of post-traumatic stress disorder (PTSD) and adverse childhood experiences (ACEs) among victims of interpersonal violence participating in a hospital-based violence intervention program. Participants completed PTSD and ACE screenings four to six weeks after violent injury, and data were exported from a case management database for analysis. Of the 35 program participants who completed the ACE and/or PTSD screenings, 75.0% met full diagnostic criteria for PTSD, with a larger proportion meeting diagnostic criteria for symptom-specific clusters. For the ACE screening, 56.3% reported three or more ACEs, 34.5% reported five or more ACEs, and 18.8% reported seven or more ACEs. The median ACE score was 3.5. These findings underscore the importance of trauma-informed approaches to violence prevention in urban hospitals and have implications for emergency medicine research and policy.

Increasing consumption of fruits and vegetables in the school cafeteria: the influence of active choice

Abstract: This study evaluated a setting-level intervention designed to increase consumption of fruits and vegetables among low-socioeconomic status elementary and middle school students participating in the National School Lunch Program (NSLP). The NSLP provides students with access to fruits and vegetables; however, food served does not necessarily equal food consumed. High rates of waste, especially of fruits and vegetables, are well documented. The current, low-cost intervention altered the choice architecture of the cafeteria by introducing an active, forced choice into the school lunch service. Consumption was measured by observing (n=2,064) and weighing (n=84) student plate waste over two 10-day periods pre-intervention and during implementation. Results show an average daily 15% increase in consumption of both fruits and vegetables during the intervention period. These findings suggest that local schools can actively encourage students to take advantage of fruits and vegetables offered through the NSLP by implementing setting-level changes to the cafeteria environment.

Factors contributing to poor physical health in incarcerated women.

Abstract: Prisons have become the primary health care provider for some of the poorest and sickest women in the United States By virtue of both biological sex and gender, incarcerated women have health needs different from those of their male counterparts The purpose of this qualitative investigation was to understand better women's perceptions of how prison has affected their physical health We conducted this investigation in a maximum-security women's prison in the United States using focus group methodology (12 focus groups, made up of 65 women) Women described several specific prison-based factors that affected their physical health: limited and complicated access to care; nutritional concerns; limited physical activity; and smoking in prison We discuss these findings in relation to the gender-based health issues facing incarcerated women

The development and evaluation of a compassion scale.

Abstract: Compassion is the capacity for being moved by suffering of others and wanting to help alleviate it. Compassion may mediate health benefits and hazards of social networks/relationships. The monitoring/management of level of compassion across social networks/relationships may be critical to health benefits' preservation and social networks/relationships' health hazards prevention. We developed and evaluated the psychometric properties of 10-item self-report measure of compassion among 310 respondents from the University and surrounding communities. The mean total score was 3.62 (SD=1.09). The item-to-total correlations ranged from 0.50-0.71. The mean inter-item correlation was 0.33. The internal consistency was 0.82. The scale correlated well with Sprecher and Fehr's Compassionate Love Scale (r=0.66; p=.000). Two factors measuring same construct explained 57% of sample variance. The scale is user-friendly, easy to score, and characterized by good psychometric properties. It can be used to foster understanding of the impact of compassion on disease and outcomes across social networks/relationships.

Decision-making processes of patients who use the emergency department for primary care needs.

Abstract: Emergency department (ED) use for non- urgent needs is widely viewed as a contributor to various health care system fl aws and ineffi ciencies. There are few qualitative studies designed to explore the complexity of patients' decision- making process to use the ED vs. primary care alternatives. In this study, semi- structured interviews were conducted with 30 patients who were discharged from the low acuity area of a university hospital ED. A grounded theory approach including cycles of immersion/crystallization was used to identify themes and reportable interpretations. Patients reported multiple decision- making considerations that hinged on whether or not they knew about primary care options. A model is developed depicting the complexity and variation in patients' decision- making to use the ED. Optimizing health system navigation and use requires improving objective factors such as access and costs as well as subjective perceptions of patients' health care, which are also a prominent part of their decision- making process.

African American men's and women's perceptions of clinical trials research: focusing on prostate cancer among a high-risk population in the South.

Abstract: While African Americans are at a significantly higher risk for developing certain cancers, they also have low rates of participation in cancer research, particularly clinical trials. This study assessed both African American men’s and African American women’s (1) knowledge of and participation in cancer-related clinical research and (2) barriers to and motivations for participating in clinical research. Data were collected from a total of 81 participants. Phase I of this research consisted of qualitative focus groups (all 81 participants). Phase II included quantitative pre/post survey data from an education program (56 participants). Findings from the study revealed that African American men and women had poor knowledge about clinical trials and the informed consent process, limited experience in participating in clinical trials, and they feared and mistrusted cancer research. Participants identified incentives, assurance of safety, knowledge and awareness, and benefiting others as motivators to participate in clinical trials research.

Health Literacy, Physician Trust, and Diabetes-related Self-care Activities in Hispanics with Limited Resources

Abstract: Background . Hispanics with diabetes often have deficits in health literacy (HL). We examined the association among HL, psychosocial factors, and diabetes-related self-care activities. Methods . Cross-sectional analysis of 149 patients. Data included patient demographics and validated measures of HL, physician trust, self-efficacy, acculturation, self-care behaviors, and A1c. Results . Participants (N=60) with limited HL were older and less educated, and had more years with diabetes compared with adequate HL participants (N=89). Limited HL participants reported greater trust in their physician, greater self-efficacy, and better diet, foot care, and medication adherence. Health literacy status was not associated with acculturation or A1c. In adjusted analyses, HL status remained associated with physician trust, and we observed a notable but nonsignificant trend between HL status and medication adherence. Discussion . Lower HL was associated with greater physician trust and better medication adherence. Further research is warranted to clarify the role of HL and physician trust in optimizing self-care for Hispanics.

Awareness of Critical Danger Signs of Pregnancy and Delivery, Preparations for Delivery, and Utilization of Skilled Birth Attendants in Nigeria

Abstract: Maternal mortality in northern Nigeria is among the highest in the world. To understand better the pathways through which the socio-demographic environment affects awareness of obstetric danger signs (i.e., potential problems associated with pregnancy), preparations for delivery, and skilled birth attendance, we conducted a survey of 5,083 women with recent pregnancies in three northern Nigerian states. Only 25% attended antenatal care (ANC), and 91% of all births took place at home. Less than one-third knew three or more danger signs of pregnancy or labor and delivery. Higher socioeconomic status was associated with knowledge of danger signs, but not with knowledge of life-threatening, critical danger signs. Antenatal care visits did not increase knowledge of critical danger signs, but they were associated with skilled birth attendance. Knowledge of critical pregnancy danger signs also was associated with skilled birth attendance. Improving the quality and coverage of ANC will ensure greater awareness of the critical danger signs. Future research is needed to identify creative and innovative ways to strengthen strategies for educating pregnant women about danger signs and in facilitating uptake of delivery services.

Factors Associated with Geriatric Syndromes in Older Homeless Adults

Abstract: Although older homeless adults have high rates of geriatric syndromes, risk factors for these syndromes are not known. We used multivariable regression models to estimate the association of subject characteristics with the total number of geriatric syndromes in 250 homeless adults aged 50 years and older. Geriatric syndromes included falls, cognitive impairment, frailty, major depression, sensory impairment, and urinary incontinence. A higher total number of geriatric syndromes was associated with having less than a high school education, medical comorbidities (diabetes and arthritis), alcohol and drug use problems, and difficulty performing one or more activities of daily living. Clinicians who care for older homeless patients with these characteristics should consider screening them for geriatric syndromes. Moreover, this study identifies potentially modifiable risk factors associated with the total number of geriatric syndromes in older homeless adults. This knowledge may provide targets for clinical interventions to improve the health of older homeless patients.

Barriers to attending an eye examination after vision screening referral within a vulnerable population.

Abstract: Half of high-risk, uninsured/underinsured individuals identified through vision screening as needing eye exams do not attend. Patients who attended vision screening and were referred for an exam but did not attend that exam were contacted and asked whether they were interested in receiving a free complete eye exam at an offsite center within three blocks of the clinic. Those who agreed were asked why they did not attend their original appointment and what would make it easier to attend. Primary reasons for missing appointments included forgetting (34%), lacking transportation (36%), and scheduling conflicts (26%). Nearly one quarter (24%) stated they could not afford transportation. Findings demonstrate transportation is a key barrier to eye care services. Current eye care delivery can be improved by addressing barriers to attendance in this context. Alternative delivery models should be examined to identify methods for better reaching underserved target populations.

Reducing Disparities in Access to Primary Care and Patient Satisfaction with Care: The Role of Health Centers

Abstract: This paper examined disparities in access to and satisfaction with primary care among patients of different racial/ethnic groups and insurance coverage, in health centers and the nation overall. Data came from the 2009 Health Center Patient Survey and 2009 Medical Expenditure Panel Survey. Study outcomes included usual source of care, type of usual source of care, satisfaction with provider office hours, and satisfaction with overall care. Health center patients were more racially and ethnically diverse than national patients, and health center patients were more likely than national patients to be uninsured or publicly insured. No significant health care disparities in access to care existed among patients from different racial/ethnic and insurance groups among health centers, unlike low-income patients nationwide or the U.S. population in general. Additional focus on the uninsured, in health centers and other health care settings nationwide, is needed to enhance satisfaction with care among these patients.

Black white disparities in receiving a physician recommendation for colorectal cancer screening and reasons for not undergoing screening.

Abstract: There is consensus that all adults over 50 years of age, regardless of gender, race, or ethnicity, should receive a physician recommendation for colorectal cancer (CRC) screening. Disparities in CRC screening result in poorer health outcomes for Blacks than for Whites. The purpose of this study was to determine whether there are Black-White differences in receiving a physician recommendation for CRC screening and reasons for undergoing screening. With 12,729 U.S. adults ages 50 to 74 included in the analysis, Whites were more likely than Blacks to report receiving a physician recommendation for CRC screening. Based on age-adjusted odds ratio, one out of three Blacks were less likely to report receiving a CRC screening recommendation from their physician (OR=0.68, 95% CI 0.57,0.81). This association persisted after adjusting for socioeconomic and other health-related factors (OR=0.61; 95% CI 0.53,0.71). This study suggests that additional steps need to be taken to reduce cancer health disparities.

Does Distance Decay Modelling of Supermarket Accessibility Predict Fruit and Vegetable Intake by Individuals in a Large Metropolitan Area

Abstract: Obesity, a risk factor for hypertension, diabetes, and other chronic diseases is influenced by geographic accessibility to supermarkets, which has been shown to affect nutritional behaviors. Purpose . To determine how individual fruit and vegetable (FV) consumption was independently influenced by accessibility to supermarkets, and to quantify that relationship. Methods . A distance decay based model was specified for a random sample (n=7,514) of urban residents. Associations between FV consumption and accessibility to supermarkets were explored, controlling for factors known to influence eating behaviors. Results . There was as independent effect of accessibility to supermarkets, even after the inclusion of the significant controlling factors of age, gender, race/ethnicity, education, marital status, and knowledge of nutritional guidelines. Conclusion . Our model of accessibility was an effective predictor of FV consumption in an urban population, setting the stage for inclusion of supply and demand parameters, and estimation of local factors that contribute to differential obesity rates.

Black Mothers' Perceptions about Urban Neighborhood Safety and Outdoor Play for their Preadolescent Daughters

Abstract: Using narratives of single low-income Black mothers with preadolescent children in a high-crime neighborhood in Newark, New Jersey, this study aims (1) to understand if and how neighborhood safety influences mothers' decisions about allowing their daughters to play outdoors and (2) to identify what neighborhood changes would need to occur to alter their perceptions about safety. Mothers reported that unpredictable violence, related to drug and gang activity of neighbors, and the absence of safe play areas in their neighborhood led them to sequester their daughters indoors. Hostile neighborhood conditions contributed to children's physical inactivity and put girls at risk for obesity.

Perceptions of harm to health from cigarettes, blunts, and marijuana among young adult African American men.

Abstract: Objectives . To assess perceptions and knowledge of health effects of smoking tobacco, blunts, and marijuana among adult African American (AA) men aged 19–30 in five Black Belt counties of rural Alabama. Methods . Cross-sectional study using interviewer-administered oral surveys. Results . Four hundred and fifteen participants completed surveys. Cigarettes were the most common initial and current product used (40%) and there were more current than initial users of marijuana and blunts. Significantly more cigarette users (80%) felt that smoking cigarettes was harmful to health compared with marijuana (33%) and blunt (53%) users (p more natural and less addictive . Conclusions. When compared with cigarettes, knowledge of the health-related effects of smoking marijuana-containing products among young African American men is poor. Intervention strategies focusing on the adverse health effects of smoking marijuana are needed.

Health Beliefs, Attitudes and Service Utilization among Haitians

Abstract: Understanding the factors that influence health beliefs, attitudes, and service use among Haitians in the United States is increasingly important for this growing population. We undertook a qualitative analysis to explore the factors related to cancer screening and utilization of health services among Haitians in Boston. Key informant interviews (n=42) and nine focus groups (n=78) revealed that Haitians experience unique barriers to health services. These include language barriers, unfamiliarity with preventive care, confidentiality concerns, mistrust and stigma concerning Western medicine, and a preference for natural remedies. Results suggest that many Haitians could benefit from health system navigation assistance, and highlight the need for comprehensive, rather than disease-focused programs, to decrease stigma and increase programmatic reach. Faith-based organizations, social service agencies, and Haitian media were identified as promising channels for disseminating health information. Leveraging positive cultural traditions and existing communication networks could increase the impact of Haitian health initiatives.

Prevalence and Correlates of Breast and Cervical Cancer Screening Among a Midwest Community Sample of Low-Acculturated Latinas

Abstract: Background . Low adherence to cervical and breast cancer (CBC) screening recommendations contributes to high CBC mortality among Latinas. Purpose . To estimate the prevalence of, and factors associated with, last 12-month Pap smear and mammogram receipt among a Midwest community sample of low-acculturated Latinas. Methods . We conducted a cross-sectional study with 278 Latina immigrants in Dane County, Wisconsin. Participants completed a self-administered questionnaire. We estimated multivariate logistic regression models to identify factors associated with CBC screening receipt. Results . Rates of last 12-month Pap smear and mammogram receipt were 56.8% and 39.4%, respectively. Age, knowledge of screening recommendations, and having a regular health care provider were independently associated with both Pap smear and mammogram receipt. Having ever used Planned Parenthood and fear of cancer were uniquely correlated with Pap smear and mammogram receipt, respectively. Conclusions . Modifiable individual, structural, and cultural factors contribute to suboptimal rates of CBC screening among low-acculturated Latino immigrants.

A Tailored Prostate Cancer Education Intervention for Low-income African Americans: Impact on Knowledge and Screening

Abstract: African American men bear disproportionate burden of prostate cancer (PCa) that can be reduced by early detection. A 15-minute culturally appropriate PCa education intervention developed to communicate effective, relevant, and balanced PCa screening information to low-income African American men was evaluated in men 42 years and older who had not been screened in one year. Of 539 men enrolled, 392 (72.7%) completed the six-month follow-up. Mean age was 54.4±8.9, 34.7% had no high school diploma, and 65.3% earned less than $25,000 annually. Barriers to screening included health insurance (41.4%), discomfort of digital rectal exam (32.1%), and fear of cancer diagnosis (29.9%). Mean knowledge score of 21 points increased from 13.27±3.51 to 14.95±4.14 (p<.001), and prostate-specific antigen screening from 22.1% to 62.8%. Men without high school diploma recorded the lowest post-intervention PCa knowledge and screening rate (47.7%), suggestive of the need for more than a single education session. Annual physicals with free prostate examination can maintain the positive trend observed.

Barriers and facilitators of cervical cancer screening among women of Hmong origin.

Abstract: This qualitative study explored the barriers and facilitators of cancer screening among women of Hmong origin. Using a community-based participatory research approach, we conducted focus groups (n=44) with Hmong women who represented four distinct demographic groups among the Hmong community. The participants described sociocultural barriers to screening, which included a lack of accurate knowledge about the causes of cervical cancer, language barriers, stigma, fear, lack of time, and embarrassment. Structural barriers included attitudes and practices of health care providers, lack of insurance, and negative perceptions of services at clinics for the uninsured. Health care providers may require additional training and increased time per visit to provide culturally sensitive care for refugee groups such as the Hmong. Health-related social marketing efforts aimed at improving health literacy may also help to reduce health inequities related to cancer screening among the Hmong.

Measuring and Assessing Preventive Medicine Services in a Student-Run Free Clinic

Abstract: We conducted a chart review of 119 patients between June 2008 and June 2009, in order to determine the rates of seven preventive medicine services in our student-run free clinic. We compared our results with national goals as well as with the national adherence rates and the adherence rates of other community clinics. We found that our clinic met or exceeded the standard set by these clinics with respect to smoking cessation, alcohol abuse screening, and mammography; however, it did not meet this standard with respect to colonoscopy, Pap smear, influenza vaccination, or pneumococcal vaccination. Barriers to providing these services were examined. To improve the quality of our clinic further, we reviewed the literature in order to determine potential interventions to increase the number of preventive medicine services our patients receive.

Improving the Quality of Discharge Care for the Homeless: A Patient-centered Approach

Abstract: Homeless patients are at risk for low-quality discharge care, yet there are limited patient-centered data to guide improvement. We explored relationships between assessment of housing status by hospital staff and quality of discharge care using quantitative and qualitative data from interviews and chart reviews with 98 homeless patients: 80% male, mean homelessness 2.8 years, mean age 44. Patient-reported performance of discharge care varied substantially across seven domains from 16-75% and chart review documented lower performance than patient report. Over half (56%) were not asked about their housing status and multivariable logistic regression showed assessment of housing status was independently associated with higher performance in five domains: discussions about cost of medications, physical activity levels, diet, transportation, and mental health follow-up. Qualitative data revealed patient concerns about stigmatization from disclosure of housing status. Our findings suggest that addressing housing status in acute care settings while avoiding stigmatization may improve discharge care for homeless patients.

Classification and correlates of eating disorders among Blacks: findings from the National Survey of American Life.

Abstract: Objective . To assess classification adjustments and examine correlates of eating disorders among Blacks. Methods . The National Survey of American Life (NSAL) was conducted from 2001-2003 and consisted of adults (n=5,191) and adolescents (n=1,170). The World Mental Health Composite International Diagnostic Interview (WMH-CIDI-World Health Organization 2004-modified) and DSM-IV-TR eating disorder criteria were used. Results . Sixty-six percent of African American and 59% Caribbean Black adults were overweight or obese, while 30% and 29% of adolescents were overweight or obese. Although lifetime rates of anorexia nervosa and bulimia nervosa were low, binge eating disorder was high for both ethnic groups among adults and adolescents. Eliminating certain classification criteria resulted in higher rates of eating disorders for all groups. Conclusion . Culturally sensitive criteria should be incorporated into future versions of Diagnostic Statistical Manual ( DSM) classifications for eating disorders that consider within-group ethnic variations.

Project ECHO: replicating a novel model to enhance access to hepatitis C care in a community health center.

Abstract: Project Extension for Community Healthcare Outcomes (Project ECHOTM) is an innovative telemedicine program that improves patient care by developing and supporting the competence of primary care providers. The Community Health Center, Inc. replicated this model to address significant access issues and improve hepatitis C management and treatment for its patients.

Providers' Perceptions of Parental Concerns about HPV Vaccination

Abstract: Objective. Parental resistance is oft en posited to explain low rates of human papil- lomavirus (HPV) vaccine uptake. We sought to describe providers' perceptions of parents' attitudes towards HPV vaccination. Methods. Thirty- four providers from four federally qualifi ed community health centers participated in semi- structured interviews related to their experiences discussing HPV vaccination with low- income and minority parents. Results. Providers found that parents were eager to prevent cancer in their daughters. Safety concerns and feeling that vaccination was unnecessary for virgins were reasons for declining vaccination. Providers found that immigrants from low- resource settings were more receptive to HPV vaccination than White middle- class parents due both to personal experience with vaccine- preventable diseases and cervical cancer and more realistic impres- sions of their children's sexual activity. Conclusions. Immigrants from low- resource settings may be particularly receptive to HPV vaccination, while White middle- class parents may be more likely to defer vaccination due to concerns about safety or sexual issues.

Racial Disparities in Receiving Total Hip/Knee Replacement Surgery: The Effect of Hospital Admission Sources

Abstract: Using a nationally-representative inpatient care dataset (the HCUP National Inpatient Sample from 2002 to 2007) we examined racial disparities in receiving total hip replacement (THR) and total knee replacement (TKR) surgeries. Multivariable logistic regression models revealed that racial minorities were significantly less likely to receive THR or TKR than Whites, controlling for patients' hospital admission source and hospital characteristics. Employing Blinder-Oaxaca decomposition techniques, we found that observed difference in population characteristics explained 55%-67% and 78% of the racial disparities in THR and TKR, respectively. Differences in patients' hospital admission source emerged as the major individual factor associated with these disparities, explaining 57%-77% of racial disparities in THR and 26%-50% of racial disparities in TKR. This study suggests that substantive racial and ethnic disparities exist in utilization of THR and TKR surgery. Observed population characteristics accounted for most of these differences, with hospital admission source being the key factor.