Differences Between Men and Women in the Rate of Use of Hip and Knee Arthroplasty.

Hawker GA, Wright JG, Coyte PC, et al (Department of Medicine, Division of Rheumatology, Faculty of Medicine, University of Toronto; Sunnybrook and Women's College Health Sciences Centre; Clinical Epidemiology and Health Care Research Program; Department of Surgery, Division of Orthopaedic Surgery, Hospital for Sick Children; Departments of Family and Community Medicine, Health Administration, and Public Health Services, University of Toronto; Department of Family and Community Medicine, St Michael's Hospital; Arthritis Community Research and Evaluation Unit, Wellesley Hospital Research Institute; Institute for Clinical Evaluative Sciences, Toronto, Canada), N Engl J Med. 2000;342:1016-1022.

This study attempted to determine whether gender differences exist in the potential need for and willingness to undergo arthroplasty. In phase 1 of the study, a brief questionnaire was mailed to 48,218 residents from 2 regions of Ontario, Canada, who were 55 years of age or older. The questionnaire asked recipients to identify symptoms of arthritis on a pain diagram, disclose the presence of functional disabilities, and report any previous arthroplasty procedures. After 2 additional mailings, nonresponders were telephoned.

In phase 2, respondents with at least moderately severe hip or knee arthritis completed 3 additional questionnaires: the Western Ontario McMaster University Osteoarthritis Index (WOMAC), the 36-item Short-Form Health Survey, and the disability subscale of the Health Assessment Questionnaire. In addition, the respondents identified any treatment or consultation by a physician regarding 18 specific health problems during the previous year.

In phase 3, all subjects at one study area with "severe" arthritis and a random sampling of those with "mild" to "moderate" arthritis received a standardized joint examination and radiographs. In both study areas, a standardized interview was conducted with subjects who had "severe" arthritis to determine their willingness to undergo arthroplasty.

In this study, persons with a potential need for arthroplasty were defined as those with "severe" arthritis (WOMAC score [is greater than or equal to] 39), no absolute contraindications to surgery, and both clinical and radio-logic evidence of arthritis.

The overall response rates for questionnaires and interviews were 72% or higher. In comparison with men, women had greater arthritis pain, were more likely to be disabled, and were more likely to require personal assistance in performing daily activities, largely because they were more likely to live alone. Women were also more likely to report that a physician had given them a diagnosis of arthritis. Despite their equal willingness to have surgery, fewer women than men had discussed the possibility of arthroplasty with a physician. Phase 1 responders with a potential need for arthroplasty were 44.9 per 1000 among women and 20.8 per 1000 among men. After adjustment for willingness to undergo the procedure, the findings for potential need for the procedure were 5.3 per 1000 for women and 1.6 per 1000 for men.

The authors concluded that arthroplasty was underused for severe arthritis in both sexes, but that the degree of underuse was more than 3 times as great in women as in men. To explain the findings, the authors theorized that barriers, perceived or actual, which are unique to women, exist between the primary care provider and the patient during the referral process for orthopedic surgery.

Paul J Burke, PT, CSCS Broomall, Pa