Numerous studies indicate substantial and sustained improvement in patients’ quality of life [32
] with low complication and revision rates [18
] after TJA. While there is low utilization of TJA among medically appropriate and willing candidates in both genders, there is an even lower utilization among women [33
]. The multistep framework we propose breaks down the patient and physician decision-making process of referral and recommendation for TJA and allows for identification of possible etiologies of gender disparity.
Our literature review used to develop this framework has some limitations. First, we used only one search engine and there was no attempt to combine the results in a meta-analysis, contact study authors, or assess the methodologic quality of studies cited. However, our review qualifies as a scoping review. Second, we only included published studies and acknowledge a search of the gray literature would have reduced the possibility of a publication bias. Third, a bulk of the literature in this area comes from outside the United States, from countries with socialized medicine, where lengthy waits for surgery exist. There is good evidence of gender disparity in TJA utilization in both Canada and the United Kingdom. A gender disparity in the rates of use of TJA may not exist in the United States; while there are some data to suggest it does [26
], a similar population-based study has not yet been performed in the United States. Finally, we limited our framework to patients who recognize their OA as treatable and seek care. Many individuals with disabling hip or knee OA do not view their OA as a disease [16
] and therefore never reach Step 1.
Where are we now? It is clear female gender is a barrier to surgery. Inequities identified in Steps 3 through 8 play an important role in explaining gender disparity in TJA utilization. Barriers unique to women exist in their interaction with their primary care physician in the process of referral to orthopaedic surgery and with their orthopaedic surgeon in the process of recommendation for TJA.
Our review identifies important gaps in knowledge and a focus for future research. We need more research on the effect of patient gender on the patient-physician interaction during the clinical encounter. Do patients voice their specific concerns and information needs and how do physicians interpret them? Qualitative studies of recorded routine office visits should be used to investigate the content of patient-physician conversations and the process of relationship building and how this influences physicians’ treatment recommendations. So far, there has been one study of this nature in the context of TJA looking at racial disparity [46
]. Using standardized patients would allow us to examine the effect of patient gender when the chief complaint, presenting symptoms, and other medically relevant factors are the same [6
We did not identify any studies evaluating an intervention to reduce the gender disparity in TJA utilization. A previous systematic review found few studies evaluating interventions to improve healthcare quality or reduce healthcare disparities in any disadvantaged populations with OA and none of these targeted physicians [8
]. Particularly important in achieving gender equity in TJA utilization are interventions that address the issues of misperceptions about the risks of, indications for, and expected outcomes of TJA among patients, primary care physicians, and the general public; physicians not recognizing the seriousness of women’s symptoms; gender bias influencing clinical decision-making; and women’s concerns and information needs about having TJA.
Where do we need to go? Closing the gender gap in TJA utilization is likely to require a multiple-intervention approach. There are a number of interventions worthy of future evaluation. We recommend focusing on developing and evaluating interventions that not only improve the quality of the patient-physician interaction but also reduce gender disparity in rates of use of TJA. Thus, the evaluation of the intervention must include comparing the difference in effect between women and men [8
How do we get there? Primary care physicians are inconsistent about the level of pain and disability that warrants TJA [17
]. Primary care physicians also tend to overestimate the risks and underestimate the benefits of TJA [17
], waiting until the disease is far progressed and thus capacity to benefit from TJA is less [22
]. These findings are not surprising, as many primary care physicians lack sufficient musculoskeletal training [27
] and no treatment guidelines currently exist, beyond expert consensus reports, regarding which patients should be considered for TJA [52
]. We still do not know how best to evaluate pain, functional disability, or capacity to benefit, nor have cut points on valid and reliable scales been determined above or below which TJA should be recommended. Tools to assist physicians and their patients in decision-making about TJA are needed. Mass media campaigns [12
] may help the general public, healthcare providers, and patients to simultaneously learn about the indications for and expected outcomes of TJA and the potential benefits of treatment earlier in the course of decline due to OA [22
Orthopaedic surgeons may require interventions that help them to recognize the severity of a female patient’s symptoms. For example, patient preference reports (a decision support tool for knee OA) clearly specifying the severity of a patient’s clinical condition and summarizing a patient’s individual concerns [64
] may result in physicians recognizing the seriousness of women’s symptoms, paying attention to the task cues rather than the social cues or presentation style. In addition, cultural competency training [2
] and shared decision-making skills [11
] programs as a core component of medical education emphasize a patient-centered approach that may help to remedy gender disparity [3
]. Patient-centered care promotes that each person should be viewed as a “unique human being” [13
] and equalizes the power imbalance between physicians and patients [15
]. Other educational interventions include skills programs that increase physicians’ acceptance and awareness of the unconscious biases that may be affecting their clinical decision-making [19
Another important factor is that we may not be addressing patients’ concerns and information needs about having TJA. Good-quality patient decision aids with evidence-based information about the risks and benefits of TJA help patients to make informed decisions about TJA [64
]. Current patient decision aids could be used to improve the patient-orthopaedic surgeon interaction and empower the female patient in the decision-making process. When patients arrive at their surgical consultation prepared and informed, the surgeon can focus on issues of concern to the individual patient, leading to a more efficient clinical encounter and care that is patient-centered. Research is also needed to determine whether current patient decision aids should be tailored to women.
In summary, by separating the decision-making process into eight discrete steps, it becomes clear that barriers unique to women exist at the level of the patient-physician interaction. It is time to evaluate whether interventions that improve the quality of the patient-physician interaction are effective in reducing the gender disparity in rates of use of TJA.