Lack of evidence for gender bias in the utilization of total hip arthroplasty among Olmsted County, Minnesota residents with osteoarthritis

Sex differences in osteoarthritis prevalence, pain perception, physical function and therapeutics

OBJECTIVE

Women have a higher prevalence of osteoarthritis (OA) and worse clinical courses than men. However, the underlying factors and therapeutic outcomes of these sex-specific differences are incompletely researched. This review examines the current state of knowledge regarding sex differences in OA prevalence, risk factors, pain severity, functional outcomes, and use and response to therapeutics.

METHODS

PubMed database was used with the title keyword combinations "{gender OR sex} AND osteoarthritis" plus additional manual search of the included papers for pertinent references, yielding 212 references. Additional references were added and 343 were reviewed for appropriateness.

RESULTS

Globally, women account for 60% of people with osteoarthritis, with a greater difference after age 40. The higher risk for women may be due to differences in joint anatomy, alignment, muscle strength, hormonal influences, obesity, and/or genetics. At the same radiographic severity, women have greater pain severity than men, which may be explained by biologically distinct pain pathways, differential activation of central pain pathways, differences in pain sensitivity, perception, reporting, and coping strategies. Women have greater limitations of physical function and performance than men independent of BMI, OA severity, injury history, and amount of weekly exercise. Women also have greater use of analgesic medications than men but less use of arthroplasty and poorer prognosis after surgical interventions.

CONCLUSIONS

The recognition of sex differences in OA manifestations and management could guide tailoring of sex-specific treatment protocols, and analysis of sex as a biological variable in future research would enhance development of precision medicine.

Examining sex and gender disparities in total joint arthroplasty

BACKGROUND

Total joint arthroplasty (TJA) is remarkably successful for treating osteoarthritis: most patients see substantial gains in function. However, there are considerable geographic, racial, and gender variations in the utilization of these procedures. The reasons for these differences are complex.

QUESTIONS/PURPOSES

We examined sex and gender disparities in TJA.

METHODS

Through Medline/PubMed searches, we identified 632 articles and from these selected 61 for our review. WHERE ARE WE NOW?: A number of factors might explain sex and gender disparities in TJA: underrepresentation in clinical trials, differences in willingness to undergo surgery, pain responses to underlying disease and treatment, patient-physician relationships, treatment preferences, provider-level factors such as physician-patient communication style, and system-level factors such as access to specialist care. Since women have a higher prevalence of arthritis and degenerative joint diseases and overall demand for these procedures will continue to grow, the need to understand why there is a gap in utilization based on gender is imperative. WHERE DO WE NEED TO GO?: Understanding what exactly is meant by "disparity" is essential because it is possible anatomic factors may have different impacts on utilization from cultural factors. Ideally, information about these factors should be integrated into the decision-making process so that patients and providers can make the most informed choice about whether or not to undergo the procedure. HOW DO WE GET THERE?: To better understand all of the potential reasons for how anatomic and cultural factors related to sex and gender might impact decision-making and overall utilization of TJA, more research focusing on these factors must be designed and carried out.

Influence of gender on age of treatment with TKA and functional outcome

BACKGROUND

Previous studies suggest differences may exist between men and women in terms of knee function before and after total knee replacement. This may be related to the efficacy of the procedure itself or to differences in the severity of disability of male and female patients at the time of surgery.

QUESTIONS/PURPOSES

We evaluated differences in the age, preoperative deformity, range-of-motion, and Knee Society scores of men and women who underwent TKA. All parameters were measured at the time of the initial preoperative evaluation and at postoperative followup.

METHODS

We studied 698 patients who underwent elective TKA between 1996 and 2007. This population consisted of 428 women (61%) and 270 men (39%), all of whom underwent rehabilitation utilizing a standardized hyperflexion protocol with immediate initiation of full weight-bearing postoperatively.

RESULTS

The men were on average three years younger than the women (mean 63.5 versus 66.6 years, respectively). Preoperative ROM, postoperative ROM, and changes in ROM and body mass index were similar between groups. Knee Society Knee scores were similar preoperatively (47.4 [men] versus 46.7 [women]), but four points higher in men at followup (89.2 versus 85.2). Women had lower Knee Function scores than men preoperatively (45.2 versus 57.1), and postoperatively (65.3 versus 73.9).

CONCLUSIONS

Women who undergo TKA seek treatment at a later stage than men and have greater functional disability at the time of surgery. Differences in functional scores persist after TKA. Earlier initiation of treatment may enhance postoperative outcome.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Gender differences in functional status and pain in a Medicare population undergoing elective total hip arthroplasty

BACKGROUND

The major indication for total hip arthroplasty (THA) is pain and disability in the hip. Evidence from state and local studies suggests that women may be more disabled than men at the time of THA. Whether worse disability at the time to THA affects outcomes is unknown.

OBJECTIVE

To examine differences in functional status and pain in men and women at the time of THA and at 1 year in a nationally representative Medicare population.

METHODS

Cohort of patients undergoing THA. Data were collected at the time of THA, 4 to 6 months after surgery, and 1 year after surgery.

SETTING

All Medicare recipients older than age 65 in 12 selected states were eligible.

PATIENTS

One thousand six hundred forty patients who underwent THA were identified and 1120 (432 men and 688 women) were enrolled.

MAIN OUTCOME MEASURES

Pain and functional status.

RESULTS

At the time of THA, women were more likely than men to report severe pain with walking (67% vs. 58%; P <0.01), and needing assistance with walking (56% vs. 45%; P <0.01), housework (49% vs. 30%; P <0.01), and grocery shopping (51% vs. 31%; P <0.01). Men could also walk greater distances. These differences persisted after adjustment for comorbidities and age. One year following THA, women were more likely to report needing assistance with walking (30% vs. 21%; P <0.01), housework (29% vs. 23%; P <01), and grocery shopping (27% vs. 19%; P <0.01) and could walk shorter distances. These differences were partially accounted for by differences in comorbidities and baseline status.

CONCLUSION

Compared with men, women in Medicare are more disabled at the time of THA and do not do as well at 1 year. Whether this difference arises from patients' preferences or bias in the health care system is unknown.

The impact of health status on waiting time for major joint arthroplasty

This study was conducted to determine the impact of health status on waiting time for major joint arthroplasty in a universal publicly funded health system. Data were collected prospectively from a cohort of 553 patients waiting for total hip or total knee arthroplasty. The WOMAC and SF-36 health status instruments were administered at the time the patient was placed on the waiting list. The outcome measure was length of waiting time. Multivariate analyses found increased body mass index and decreased social function as the only determinants of waiting time. This model explained only 4% of the variance in waiting time. The association between health status and waiting time for arthroplasties appears to be small. These findings suggest that major joint arthroplasty is not prioritized on the basis of burden of illness.

Gender differences in patient preferences may underlie differential utilization of elective surgery

PURPOSE

To study gender-specific preferences regarding timing of elective total joint replacement (TJR) surgery in patients with moderately severe osteoarthritis (OA) of the hip or knee.

PATIENTS AND METHODS

Focus group discussions regarding TJR surgery were conducted among 18 women and among 12 men with moderately severe OA of the hip or knee. Discussions were tape recorded, transcribed, coded for themes, and evaluated semiquantitatively and qualitatively for gender differences.

RESULTS

In general, men were more likely to choose surgery earlier in the disease than women and had higher expectations for surgical success. Women were more fearful of surgery. Women preferred to suffer arthritis pain rather than risk surgery, and indicated they would delay surgery to await better technology and to avoid disrupting caregiving roles for dependent spouses and others.

CONCLUSION

Men and women differ in their willingness to accept continued functional decline, risks of surgery, and disruption of usual role. Gender differences may influence decisions regarding utilization of TJR.

Differences in symptom reports between men and women with rheumatoid arthritis

OBJECTIVE

To determine if differences exist between men and women in their reports and evaluations of rheumatoid arthritis (RA) symptoms, and, if so, to identify explanations of those differences.

METHOD

Data from a longitudinal panel study of persons with RA were used. Symptom reports were defined as individuals' evaluation of body states, e.g., evaluations of the severity of pain. Analyses were controlled for sociodemographic, clinical, and psychological characteristics.

RESULTS

In unadjusted analyses, women were more likely to evaluate their symptoms as severe. Adjustment for sociodemographic and clinical characteristics changed these results very little. Controlling for depressive symptoms decreased the magnitude of associations somewhat. Analyses controlling for additional respondent-reported clinical characteristics (Health Assessment Questionnaire score, number of painful joints) yielded dramatically different results; in no case did women evaluate their symptoms significantly more severely than men.

CONCLUSION

Our analyses suggest that women reported more severe symptoms, but that these differences may be due to more severe disease rather than a tendency by women to over-report symptoms or over-rate symptom severity. Future research should examine whether physicians respond to reports or prescribe treatments differently for men and women.

Need for bilateral arthroplasty for coxarthrosis. 1,477 replacements in 1,199 patients followed for 0-14 years

During the 10-year period 1981-1990, 1,199 patients in the county of South Jutland, Denmark, had 1,477 primary total hip arthroplasties (THA) performed because of primary arthrosis (OA). The patients were followed until the end of 1994, with a mean follow-up of 5.6 (0-14) years. Bilateral operations were performed on 356 patients, whereas 248 patients had died with only 1 THA. The cumulated risk of replacement of the contralateral hip was approximately 0.15 1 year after replacement of the first hip, 0.20 after 2 years, 0.29 after 5 years and 0.47 after 10 years, respectively. During the follow-up period, the demand for a THA of the contralateral hip continued to be approximately 15 times higher than in the general population.