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Patient Gender Affects the Referral and Recommendation for Total Joint Arthroplasty

  • Symposium: AAOS/ORS/ABJS Musculoskeletal Healthcare Disparities Research Symposium
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

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.

Questions/purposes

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.

Methods

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.

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References

  1. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004 National Healthcare Disparities Report. December 2004. AHRQ Publication Number 05-0014. Available at: http://www.ahrq.gov/qual/nhdr04/nhdr2004.pdf. Accessed November 29, 2010.

  2. Beach MC, Gary TL, Robinson KA, Gozu A, Palacio A, Smarth C, Jenckes MW, Feuerstein C, Bass EB, Powe NR, Cooper LA. Cultural competence: a systematic review of health care provider educational interventions. Med Care. 2005;43:356–373.

    Article  PubMed  Google Scholar 

  3. Beach MC, Rosner M, Cooper LA, Duggan PS, Shatzer J. Can patient-centered attitudes reduce racial and ethnic disparities in care? Acad Med. 2007;82:193–198.

    Article  PubMed  Google Scholar 

  4. Bertakis KD, Azari R, Helms LJ, Callahan EJ, Robbins JA. Gender differences in the utilization of health care services. J Fam Pract. 2000;49:147–152.

    PubMed  CAS  Google Scholar 

  5. Birdwell BG, Herbers JE, Kroenke K. Evaluating chest pain: the patient’s presentation style alters the physician’s diagnostic approach. Arch Intern Med. 1993;153:1991–1995.

    Article  PubMed  CAS  Google Scholar 

  6. Borkhoff CM, Hawker GA, Kreder HJ, Glazier RH, Mohamed NN, Wright JG. The effect of patients’ sex on physicians’ recommendations for total knee arthroplasty. CMAJ. 2008;178:681–687.

    PubMed  Google Scholar 

  7. Borkhoff CM, Hawker GA, Kreder HJ, Glazier RH, Mohamed NN, Wright JG. The influence of patients’ gender on physicians’ interpersonal behaviour regarding total knee arthroplasty: what if your physician doesn’t ask you to dance? Osteoarthritis Cartilage. 2008;16(Suppl 4):S140.

    Article  Google Scholar 

  8. Borkhoff CM, Wieland ML, Myasoedova E, Ahmad Z, Welch V, Hawker GA, Li LC, Buchbinder R, Ueffing E, Beaton D, Cardiel MH, Gabriel SE, Guillemin F, Adebajo AO, Bombardier C, Hajjaj-Hassouni N, Tugwell P. Reaching those most in need: a scoping review of interventions to improve health care quality for disadvantaged populations with osteoarthritis. Arthritis Care Res (Hoboken). 2011;63:39–52.

    Article  Google Scholar 

  9. Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res. 2010;468:57–63.

    Article  PubMed  Google Scholar 

  10. Bourne RB, McCalden RW, MacDonald SJ, Mokete L, Guerin L. Influence of patient factors on TKA outcomes at 5 to 11 years followup. Clin Orthop Relat Res. 2007;464:27–31.

    PubMed  Google Scholar 

  11. Braddock CH, Edwards KA, Hasenber NM, Laidley TL, Levinson W. Informed decision making in outpatient practice: time to get back to basics. JAMA. 1999;282:2313–2320.

    Article  PubMed  Google Scholar 

  12. Buchbinder R. Self-management education en masse: effectiveness of the Back Pain: Don’t Take It Lying Down mass media campaign. Med J Aust. 2008;189:S29–S32.

    PubMed  Google Scholar 

  13. Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: a patient-based approach. Ann Intern Med. 1999;130:829–834.

    PubMed  CAS  Google Scholar 

  14. Chang HJ, Mehta PS, Rosenberg A, Scrimshaw SC. Concerns of patients actively contemplating total knee replacement: differences by race and gender. Arthritis Rheum. 2004;51:117–123.

    Article  PubMed  Google Scholar 

  15. Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med. 1997;44:681–692.

    Article  PubMed  CAS  Google Scholar 

  16. Clark JP, Hudak PL, Hawker GA, Coyte PC, Mahomed NN, Kreder HJ, Wright JG. The moving target: a qualitative study of elderly patients’ decision-making regarding total joint replacement surgery. J Bone Joint Surg Am. 2004;86:1366–1374.

    PubMed  Google Scholar 

  17. Coyte PC, Hawker GA, Croxford R, Attard C, Wright JG. Variation in rheumatologists’ and family physicians’ perceptions of the indications for and outcomes of knee replacement surgery. J Rheumatol. 1996;23:730–738.

    PubMed  CAS  Google Scholar 

  18. Coyte PC, Hawker GA, Croxford R, Wright JG. Rates of revision knee replacement in Ontario, Canada. J Bone Joint Surg Am. 1999;81:773–782.

    PubMed  CAS  Google Scholar 

  19. Devine PG. Stereotypes and prejudice: their automatic and controlled components. J Pers Soc Psychol. 1989;56:5–18.

    Article  Google Scholar 

  20. Einbinder LC, Schulman KA. The effect of race on the referral process for invasive cardiac procedures. Med Care Res Rev. 2000;57(Suppl 1):162–180.

    PubMed  Google Scholar 

  21. Elderkin-Thompson V, Waitzkin H. Differences in clinical communication by gender. J Gen Intern Med. 1999;14:112–121.

    Article  PubMed  CAS  Google Scholar 

  22. Fortin PR, Clarke AE, Joseph L, Liang MH, Tanzer M, Ferland D, Phillips C, Partridge AJ, Belisle P, Fossel AH, Mahomed NN, Sledge CB, Katz JN. Outcomes of total hip replacement: preoperative functional status predicts outcomes at six months after surgery. Arthritis Rheum. 1999;42:1722–1728.

    Article  PubMed  CAS  Google Scholar 

  23. Fowler RA, Sabur N, Li P, Juurlink DN, Pinto R, Hladunewich MA, Adhikari NK, Sibbald WJ, Martin CM. Sex- and age-based differences in the delivery and outcomes of critical care. CMAJ. 2007;177:1513–1519.

    PubMed  Google Scholar 

  24. Franks P, Clancy CM. Referrals of adult patients from primary care: demographic disparities and their relationship to HMO insurance. J Fam Pract. 1997;45:47–53.

    PubMed  CAS  Google Scholar 

  25. Gandhi R, Razak F, Davey JR, Rampersaud YR, Mahomed NN. Effect of sex and living arrangement on the timing and outcome of joint replacement surgery. Can J Surg. 2010;53:37–41.

    PubMed  Google Scholar 

  26. Giacomini MK. Gender and ethnic differences in hospital-based procedure utilization in California. Arch Intern Med. 1996;156:1217–1224.

    Article  PubMed  CAS  Google Scholar 

  27. Glazier RH, Dalby DM, Badley EM, Hawker GA, Bell MJ, Buchbinder R, Lineker SC. Management of common musculoskeletal problems: a survey of Ontario primary care physicians. CMAJ. 1998;158:1037–1040.

    PubMed  CAS  Google Scholar 

  28. Hall JA, Roter DL, Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Med Care. 1988;26:657–675.

    Article  PubMed  CAS  Google Scholar 

  29. Hawker GA. Who, when, and why total joint replacement surgery? The patient’s perspective. Curr Opin Rheumatol. 2006;18:526–530.

    PubMed  Google Scholar 

  30. Hawker GA, Guan J, Croxford R, Coyte PC, Glazier RH, Harvey BJ, Wright JG, Williams JI, Badley EM. A prospective population-based study of the predictors of undergoing total joint arthroplasty. Arthritis Rheum. 2006;54:3212–3220.

    Article  PubMed  Google Scholar 

  31. Hawker GA, Wright JG, Badley EM, Coyte PC. Perceptions of, and willingness to consider, total joint arthroplasty in a population-based cohort of individuals with disabling hip and knee arthritis. Arthritis Rheum. 2004;51:635–641.

    Article  PubMed  Google Scholar 

  32. Hawker GA, Wright JG, Coyte PC, Paul J, Dittus R, Croxford R, Katz B, Bombardier C, Heck D, Freund D. Health-related quality of life after knee replacement surgery: results of the knee replacement patient outcomes research team study. J Bone Joint Surg Am. 1998;80:163–173.

    PubMed  CAS  Google Scholar 

  33. Hawker GA, Wright JG, Coyte PC, Williams JI, Harvey B, Glazier R, Badley EM. Differences between men and women in the rate of use of hip and knee arthroplasty. N Engl J Med. 2000;342:1016–1022.

    Article  PubMed  CAS  Google Scholar 

  34. Hawker GA, Wright JG, Coyte PC, Williams JI, Harvey B, Glazier R, Wilkins A, Badley EM. Determining the need for hip and knee arthroplasty: the role of clinical severity and patients’ preferences. Med Care. 2001;39:206–216.

    Article  PubMed  CAS  Google Scholar 

  35. Heck DA, Melfi CA, Mamlin LA, Katz BP, Arthur DS, Dittus RS, Freund DA. Revision rates after knee replacement in the United States. Med Care. 1998;36:661–669.

    Article  PubMed  CAS  Google Scholar 

  36. Holtzman J, Saleh K, Kane R. Gender differences in functional status and pain in a Medicare population undergoing elective total hip arthroplasty. Med Care. 2002;40:461–470.

    Article  PubMed  Google Scholar 

  37. Hudak PL, Clark JP, Hawker GA, Coyte PC, Mahomed NN, Kreder HJ, Wright JG. “You’re perfect for the procedure! Why don’t you want it?” Elderly arthritis patients’ unwillingness to consider total joint arthroplasty surgery: a qualitative study. Med Decis Making. 2002;22:272–278.

    PubMed  Google Scholar 

  38. Hudak PL, Grassau P, Glazier RH, Hawker G, Kreder H, Coyte P, Mahomed N, Wright JG. “Not everyone who needs one is going to get one”: the influence of medical brokering on patient candidacy for total joint arthroplasty. Med Decis Making. 2008;28:773–780.

    Article  PubMed  Google Scholar 

  39. Hughes D, Griffiths L. “Ruling in” and “ruling out”: two approaches to the micro-rationing of health care. Soc Sci Med. 1997;44:589–599.

    Article  PubMed  CAS  Google Scholar 

  40. Juni P, Low N, Reichenbach S, Villiger PM, Williams S, Dieppe PA. Gender inequity in the provision of care for hip disease: population-based cross-sectional study. Osteoarthritis Cartilage. 2010;18:640–645.

    Article  PubMed  CAS  Google Scholar 

  41. Kaplan SH, Gandek B, Greenfield S, Rogers W, Ware JE. Patient and visit characteristics related to physicians’ participatory decision-making style: results from the Medical Outcomes Study. Med Care. 1995;33:1176–1187.

    Article  PubMed  CAS  Google Scholar 

  42. Karlson EW, Daltroy LH, Liang MH, Eaton HE, Katz JN. Gender differences in patient preferences may underlie differential utilization of elective surgery. Am J Med. 1997;102:524–530.

    Article  PubMed  CAS  Google Scholar 

  43. Katz BP, Freund DA, Heck DA, Dittus RS, Paul JE, Wright JG, Coyte P, Holleman E, Hawker GA. Demographic variation in the rate of knee replacement: a multi-year analysis. Health Serv Res. 1996;31:125–140.

    PubMed  CAS  Google Scholar 

  44. Katz JN. Patient preferences and health disparities. JAMA. 2001;286:1506–1509.

    Article  PubMed  CAS  Google Scholar 

  45. Katz JN, Wright EA, Guadagnoli E, Liang MH, Karlson EW, Cleary PD. Differences between men and women undergoing major orthopaedic surgery for degenerative arthritis. Arthritis Rheum. 1994;37:687–694.

    Article  PubMed  CAS  Google Scholar 

  46. Levinson W, Hudak PL, Feldman JJ, Frankel RM, Kuby A, Bereknyei S, Braddock CH. “It’s not what you say…”: racial disparities in communication between orthopaedic surgeons and patients. Med Care. 2008:46:410–416.

    Article  PubMed  Google Scholar 

  47. Levinson W, Kao A, Kuby A, Thisted RA. Not all patients want to participate in decision making: a national study of public preferences. J Gen Intern Med. 2005;20:531–535.

    Article  PubMed  Google Scholar 

  48. Lewis MI. An economic profile of American older women. J Am Med Womens Assoc. 1997;52:107–112.

    PubMed  CAS  Google Scholar 

  49. MacDonald SJ, Charron KD, Bourne RB, Naudie DD, McCalden RW, Rorabeck CH. The John Insall Award. Gender-specific total knee replacement: prospectively collected clinical outcomes. Clin Orthop Relat Res. 2008;466:2612–2616.

    Article  PubMed  Google Scholar 

  50. Mahomed NN, Liang MH, Cook EF, Daltroy LH, Fortin PR, Fossel AH, Katz JN. The importance of patient expectations in predicting functional outcomes after total joint arthroplasty. J Rheumatol. 2002;29:1273–1279.

    PubMed  Google Scholar 

  51. Monteith MJ. Self-regulation of prejudiced responses: implications for progress in prejudice reduction efforts. J Pers Soc Psychol. 1993;65:469–485.

    Article  Google Scholar 

  52. NIH Consensus Panel. NIH Consensus Statement on total knee replacement December 8–10, 2003. J Bone Joint Surg Am. 2004;86:1328–1335.

    Google Scholar 

  53. Ontario Ministry of Health and Long Term Care Wait Times Health Initiative. Available at: http://www.health.gov.on.ca/en/public/programs/waittimes/surgery. Accessed November 29, 2010.

  54. Parsley BS, Bertolusso R, Harrington M, Brekke A, Noble PC. Influence of gender on age of treatment with TKA and functional outcome. Clin Orthop Relat Res. 2010;468:1759–1764.

    Article  PubMed  Google Scholar 

  55. Reynolds DL, Chambers LW, Badley EM, Bennett KJ, Goldsmith CH, Jamieson E, Torrance GW, Tugwell P. Physical disability among Canadians reporting musculoskeletal diseases. J Rheumatol. 1992;19:1020–1030.

    PubMed  CAS  Google Scholar 

  56. Ritter MA, Wing JT, Berend ME, Davis KE, Meding JB. The clinical effect of gender on outcome of total knee arthroplasty. J Arthroplasty. 2008;23:331–336.

    Article  PubMed  Google Scholar 

  57. Ross S, Moffat K, McConnachie A, Gordon J, Wilson P. Sex and attitude: a randomized vignette study of the management of depression by general practitioners. Br J Gen Pract. 1999;49:17–21.

    PubMed  CAS  Google Scholar 

  58. Roter D, Lipkin M Jr, Korsgaard A. Sex differences in patients’ and physicians’ communication during primary care medical visits. Med Care. 1991;29:1083–1093.

    Article  PubMed  CAS  Google Scholar 

  59. Sale JE, Gignac M, Hawker GA. The relationship between disease symptoms, life events, coping and treatment, and depression among older adults with osteoarthritis. J Rheumatol. 2008;35:335–342.

    PubMed  Google Scholar 

  60. Santaguida PL, Hawker GA, Hudak PL, Glazier R, Mahomed NN, Kreder HJ, Coyte PC, Wright JG. Patient characteristics affecting the prognosis of total hip and knee joint arthroplasty: a systematic review. Can J Surg. 2008;51:428–436.

    PubMed  Google Scholar 

  61. Schulman KA, Berlin JA, Harless W, Kerner JF, Sistrunk S, Gersh BJ, Dubé R, Taleghani CK, Burke JE, Williams S, Eisenberg JM, Escarce JJ. The effect of race and sex on physicians’ recommendations for cardiac catheterization. N Engl J Med. 1999;340:618–626.

    Article  PubMed  CAS  Google Scholar 

  62. Seils DM, Friedman JY, Schulman KA. Sex differences in the referral process for invasive cardiac procedures. J Am Med Womens Assoc. 2001;56:151–154.

    PubMed  CAS  Google Scholar 

  63. Soohoo NF, Farng E, Lieberman JR, Chambers L, Zingmond DS. Factors that predict short-term complication rates after total hip arthroplasty. Clin Orthop Relat Res. 2010;468:2363–2371.

    Article  PubMed  Google Scholar 

  64. Stacey D, Hawker GA, Dervin G, Tomek I, Cochran N, Tugwell P, O’Connor A. Improving shared decision making in osteoarthritis. BMJ. 2008;336:954–955.

    Article  PubMed  Google Scholar 

  65. Suarez-Almazor ME. Unraveling gender and ethnic variation in the utilization of elective procedures: the case of total joint replacement. Med Care. 2002;40:447–450.

    Article  PubMed  Google Scholar 

  66. Toye FM, Barlow J, Wright C, Lamb SE. Personal meanings in the construction of need for total knee replacement surgery. Soc Sci Med. 2006;63:43–53.

    Article  PubMed  Google Scholar 

  67. Unruh AM. Gender variations in clinical pain experience. Pain. 1996;65:123–167.

    Article  PubMed  CAS  Google Scholar 

  68. Wodak R. Women relate, men report: sex differences in language behavior in a therapeutic group. J Pragmatics. 1981;5:261–285.

    Article  Google Scholar 

  69. Zimmer, Inc. Back in the Groove™ Community Healthcare Program. Available at: http://backinthegroove.zimmer.com/micro/z/ctl/op/global/action/1/id/3/template/MN/navid/28. Accessed February 2010.

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Acknowledgment

The authors thank Lynne C. Einbinder, MD, for developing the original framework adapted for this manuscript.

Author information

Authors and Affiliations

  1. Centre for Global Health, Institute of Population Health, University of Ottawa, 1 Stewart Street, Ottawa, ON, K1N 6N5, Canada

    Cornelia M. Borkhoff PhD

  2. Canadian Osteoarthritis Research Program, Women’s College Hospital, Room 817, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada

    Cornelia M. Borkhoff PhD

  3. Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

    Gillian A. Hawker MD, MSc, FRCPC

  4. Department of Medicine, Women’s College Hospital, Toronto, ON, Canada

    Gillian A. Hawker MD, MSc, FRCPC

  5. Departments of Public Health Sciences and Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

    James G. Wright MD, MPH, FRCSC

  6. Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada

    James G. Wright MD, MPH, FRCSC

Authors
  1. Cornelia M. Borkhoff PhD
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  2. Gillian A. Hawker MD, MSc, FRCPC
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  3. James G. Wright MD, MPH, FRCSC
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Corresponding author

Correspondence to Cornelia M. Borkhoff PhD.

Additional information

Cornelia M. Borkhoff is supported by a CIHR Postdoctoral Fellowship Award. Gillian A. Hawker holds the F. M. Hill Chair in Academic Women’s Medicine at the University of Toronto and is an Arthritis Society of Canada Senior Distinguished Rheumatology Investigator. James G. Wright holds the Robert B. Salter Chair in Surgical Research. Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

This work was performed at Women’s College Hospital and The Hospital for Sick Children.

Appendix 1. MEDLINE Search Strategy

Appendix 1. MEDLINE Search Strategy

The search terms for MEDLINE are listed below, along with the number of hits obtained from searching Ovid MEDLINE from 1948 to January Week 2 2011.

  1. 1.

    ((total joint or total hip or total knee or joint or hip or knee) adj 2 (surgery or arthroplasty or replacement)).mp. (34,639)

  2. 2.

    exp osteoarthritis/ (33,506)

  3. 3.

    (osteoarthritis or osteoarthros#s or degenerative joint disease).tw. (27,310)

  4. 4.

    arthritis.mp. (136,372)

  5. 5.

    or/2–4 (166,351)

  6. 6.

    (gender-based or gender-related or gender differences or gender factors).mp. (15,222)

  7. 7.

    exp sex factors/ (178,095)

  8. 8.

    ((sex or gender) adj2 (analysis or specific or difference$ or distribution$ or factor$ or inequit$ or disparit$ or inequalit$)).mp. (247,393)

  9. 9.

    or/6–8 (248,198)

  10. 10.

    9 and 5 (3391)

  11. 11.

    limit 10 to humans (3285)

  12. 12.

    11 and 1 (288)

  13. 13.

    decision making.mp. or exp Decision Making/ (129,994)

  14. 14.

    13 and 1 (225)

  15. 15.

    14 or 12 (504)

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Borkhoff, C.M., Hawker, G.A. & Wright, J.G. Patient Gender Affects the Referral and Recommendation for Total Joint Arthroplasty. Clin Orthop Relat Res 469, 1829–1837 (2011). https://doi.org/10.1007/s11999-011-1879-x

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  • DOI: https://doi.org/10.1007/s11999-011-1879-x

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