Symposium: AAOS/ORS/ABJS Musculoskeletal Healthcare Disparities Research Symposium

Clinical Orthopaedics and Related Research®

, Volume 469, Issue 7, pp 1829-1837

First online:

Patient Gender Affects the Referral and Recommendation for Total Joint Arthroplasty

  • Cornelia M. BorkhoffAffiliated withCentre for Global Health, Institute of Population Health, University of OttawaCanadian Osteoarthritis Research Program, Women’s College Hospital Email author 
  • , Gillian A. HawkerAffiliated withDepartment of Health Policy, Management and Evaluation, University of TorontoDepartment of Medicine, Women’s College Hospital
  • , James G. WrightAffiliated withDepartments of Public Health Sciences and Health Policy, Management and Evaluation, University of TorontoDepartment of Surgery, The Hospital for Sick Children

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Rates of use of total joint arthroplasty among appropriate and willing candidates are lower in women than in men. A number of factors may explain this gender disparity, including patients’ preferences for surgery, gender bias influencing physicians’ clinical decision-making, and the patient-physician interaction.


We propose a framework of how patient gender affects the patient and physician decision-making process of referral and recommendation for total joint arthroplasty and consider potential interventions to close the gender gap in total joint arthroplasty utilization.


The process involved in the referral and recommendation for total joint arthroplasty involves eight discrete steps. A systematic review is used to describe the influence of patient gender and related clinical and nonclinical factors at each step.

Where are we now?

Patient gender plays an important role in the process of referral and recommendation for total joint arthroplasty. Female gender primarily affects Steps 3 through 8, suggesting barriers unique to women exist in the patient-physician interaction.

Where do we need to go?

Developing and evaluating interventions that improve the quality of the patient-physician interaction should be the focus of future research.

How do we get there?

Potential interventions include using decision support tools that facilitate shared decision-making between patients and their physicians and promoting cultural competency and shared decision-making skills programs as a core component of medical education. Increasing physicians’ acceptance and awareness of the unconscious biases that may be influencing their clinical decision-making may require additional skills programs.