Gender Differences in Patient Preferences May Underlie Differential Utilization of Elective Surgery

doi:10.1016/S0002-9343(97)00050-8

The American Journal of Medicine

Volume 102, Issue 6, June 1997, Pages 524-530

https://doi.org/10.1016/S0002-9343(97)00050-8 Get rights and content

Abstract

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.

Section snippets

Methods

The purpose of focus group methodology is to generate revealing comments and insights about a topic in a spontaneous (but focussed) conversation among strangers. Convenience samples of subjects representative of the population of interest are used. Groups are run sequentially until new themes and insights stop emerging, typically around the fourth or fifth group.13, 14All patients with OA age 60 or older who had an office visit between September 1, 1993 and March 1, 1994 were selected from the

Characteristics of the Subjects (Table 2)

Of 90 subjects invited by mail, 41 were willing to participate, and 30 (12 men and 18 women) were able to attend 1 of 5 scheduled focus groups. Seven subjects had OA of the hip, 15 had OA of the knee, 8 had both. Mean age was 69.4 years. Two subjects were African-American, 28 were Caucasian. Men had a mean of 14.8 years of education as compared with 13.6 for women. Eight women as compared with no men lived alone (P = 0.007). Most subjects were retired and, of those with work experience, many

Discussion

Using qualitative analysis of focus group discussions, we show that men and women with moderately severe OA exhibited significant differences in factors influencing decisions regarding TJR. Women were concerned with more basic functional activities than men, such as inability to take public transportation and difficulty with bathing and dressing. This suggests that women delay seeking TJR until a later point in the process of functional decline. Women preferred to suffer with arthritis pain

Acknowledgements

The authors thank Nancy Tanner and Jackie Mazzie for transcribing the focus group discussions, and Lisa Sachs for helping with coding and sorting of comments.

Supported in part by NIH Supplement from the Office of Research on Women's Health: AR36308, an Arthritis Foundation Postdoctoral Fellowship (EWK), Arthritis Foundation Investigator Award (JNK), Clinical Science Grant from the Arthritis Foundation (LHD).

References (16)

JN Tobin et al.
Sex bias in considering coronary bypass surgery
Ann Intern Med.
(1987)
JZ Ayanian et al.
Differences in the use of procedures between women and men hospitalized for coronary heart disease
NEJM.
(1991)
RM Steingart et al.
Sex differences in the management of coronary artery disease
NEJM.
(1991)
HM Krumholz et al.
Selection of patients for coronary angiography and coronary revascularization early after myocardial infarction: is there evidence for a gender bias?
Ann Intern Med.
(1992)
SS Khan et al.
Increased mortality of women in coronary artery bypass surgery: evidence for referral bias
Ann Intern Med.
(1990)
NA Bickell et al.
Referral patterns for coronary artery disease treatment: gender bias of good clinical judgement?
Ann Intern Med.
(1992)
HM Kjellstrand
Age, sex, and race inequality in renal transplantation
Arch Intern Med.
(1988)
PW Eggers
Effect of transplantation on the medical end-stage renal disease program:
NEJM
(1988)

There are more references available in the full text version of this article.

Cited by (195)

Impact of Demographic Variables on Recovery After Total Hip Arthroplasty
2024, Journal of Arthroplasty
Several patient factors affect recovery after total hip arthroplasty (THA). However, the impact of these variables on patient-reported outcome measure recovery curves following THA has not been defined. Our goal was to quantify the influence of multiple variables on recovery after primary THA.
There were 1,724 patients in a multicenter study included. Variables included sex, race/ethnicity, anxiety/depression, body mass index, tobacco, and preoperative opioid use. The Hip disability and Osteoarthritis Score for Joint Replacement (HOOS JR) was recorded at multiple time points. Recovery curves were created using longitudinal estimating equations.
Patients who were women, obese, or smokers demonstrated lower HOOS JR scores at all time points. Preoperative opioid use was also correlated with lower HOOS JR scores, but this difference diminished after 6 months. Black patients demonstrated lower HOOS JR scores compared to Caucasians, and this relative difference increased out to 1-year postoperatively (P = .018). Hispanics also had lower HOOS JR scores, but scores recovered at similar rates compared to non-Hispanics. Patients who had only anxiety or depression had similar HOOS JR scores compared to patients who did not have anxiety or depression. However, patients who had both anxiety and depression had lower HOOS JR scores compared to patients who had neither (P = .049), and this relative difference became greater at 1-year postoperatively (P = .002).
Several factors including race/ethnicity, opioid use, and mental health influence recovery trajectory following THA. This information helps provide more individualized counseling about expectations after THA and focus targeted interventions to improve outcomes in at-risk groups.
Usage of guideline-adherent core treatments for knee osteoarthritis before and after consulting an orthopaedic surgeon: A prospective cohort study
2023, Osteoarthritis and Cartilage Open
To describe 1) the proportion of patients with knee osteoarthritis (OA) undergoing guideline-adherent core treatments until six months after primary referral to an orthopaedic surgeon, 2) which specific treatment pathways these patients undertake and 3) the characteristics of patients choosing different treatment pathways.
This prospective cohort study consecutively invited patients referred to an orthopaedic surgeon due to knee OA at two Danish hospitals from October 2018 to December 2020. Before and six months after consulting the surgeon, patients answered a questionnaire reporting which treatments they had received for knee OA. The proportion receiving the combination of guideline-adherent treatments (i.e., exercise, education, and dietary weight management if needed) was determined. We evaluated the specific treatment usage before and until six months after the consultation and investigated characteristics of patients undertaking different pathways.
Out of 5251 eligible patients, 2574 (49%) had complete data and were included in analyses. 23% received guideline-adherent treatments, 10% had no treatment. Patients underwent 1143 unique treatment pathways, 62% including treatments not recommended/recommended against. Those who underwent guideline-adherent pathways had similar characteristics to those who did not but tended to be females, retired, had longer-lasting knee problems, have comorbidities, and higher education levels.
Only one in four patients with knee OA received treatment adhering to clinical guidelines before and six months after consulting the surgeon. Patients used many different treatment pathways. There is a need for a structured effort to increase the use of guideline-adherent core treatments.
Registration: NCT03746184, Protocol: PMID: 34233992.
Disease burden of and expectations from surgery in patients prior to total knee arthroplasty: Results of the prospective FInGK study
2023, Knee
Disease burden in patients prior to total knee arthroplasty (TKA) varies widely between studies and countries. We aimed to characterize individuals undergoing TKA and examine their expectations from the surgery, focusing on variations in disease burden.
Consecutive patients undergoing primary TKA in a German university hospital were recruited. A questionnaire including information on disease burden, preoperative expectations from surgery, health care utilization, demography, and socioeconomics was collected one day prior to surgery and linked to data from medical records. Patients were categorized into disease burden quartiles using the Western Ontario and McMaster Universities Osteoarthritis Index’ (WOMAC) total score. Subsequently, study population’s characteristics and expectations from surgery were analyzed stratified by disease burden.
A total of 196 patients were included (41 % male; mean age: 68.2 years). The median WOMAC was 52.0 (IQR: 41.0–58.0). Patients in Q1 were more often males (Q1: 63 % vs Q4: 29 %) and had a shorter duration of complaints with the impaired knee. They were also less restricted in social participation, reported less often signs of depression, and were less often treated with physiotherapy (Q1: 27 % vs Q4: 54 %). Furthermore, expectations from surgery were highest in patients with a low disease burden.
We found large variations in disease burden with a considerable number of patients undergoing TKA whose functional capacity is still maintained and for which guideline-recommended conservative treatment options are not fully exhausted. Further research on this subgroup as well as establishing an international consensus on specific thresholds for TKA indication are needed.
Patients who have undergone total shoulder arthroplasty prefer greater surgeon involvement in shared decision making
2023, Journal of Shoulder and Elbow Surgery
There has been a shift in medical decision making from a paternalist model to a shared decision-making (SDM) approach, described as a patient-physician relationship where both parties collaborate to arrive on an evidence-based treatment regimen that best suits the patient's needs and values. However, there is a scarcity in evidence regarding SDM in shoulder arthroplasty. The purpose of this study was to evaluate overall patient preference for SDM and determine demographic and socioeconomic factors related to SDM preference in those undergoing shoulder arthroplasty.
Patients aged 40-89 years who had undergone a total shoulder arthroplasty were enrolled. Two-part questionnaires were administered collecting patient demographic information and SDM subscale scores postoperatively. Bivariate and multivariate regression models were used to determine factors associated with SDM Total and subscale scores.
A total of 125 patients (53 male; mean age, 69.5 ± 10.4 years) who had undergone primary total shoulder arthroplasty were included. The mean Total SDM score was −2.24 ± 1.9 and the Preoperative, Operative, and Postoperative SDM subscale scores were −1.54 ± 2.0, −2.59 ± 2.2, and −2.48 ± 2.1, respectively, indicating a preference for SDM in the Preoperative subscale and surgeon-driven decision making in the total score and other 2 subscales. Multivariate regression models demonstrated a preference for surgeon decision making at both the 4-12-week postoperative period for the Preoperative subscale (odds ratio [OR] −1.03, 95% CI −2.0, −0.1, P = .039) and the 2-4-week postoperative period for the Operative subscale (OR −1.74, 95% CI −3.4, −0.1, P = .038) when compared to patients at the 2-week postoperative period. No other variables were significantly associated with any of the SDM subscale scores or Total SDM score.
Patients reported a more passive role in the decision-making process with an overall preference for a surgeon-led approach in primary total shoulder arthroplasty. Patients preferred a shared decision-making approach in regard to preoperative considerations but indicated a significant preference for surgeon-led decision making regarding day of surgery decisions. There were no correlations between SDM scores and age, sex, race, income, education level, insurance type, or treating surgeon. Overall, patients demonstrated a predilection for an SDM approach for preoperative considerations, contrary to those decisions associated with the day of surgery and postoperative care.
Patient-level payment patterns prior to single level lumbar decompression are associated with resource utilization, postoperative payments, and adverse events
2023, Spine Journal
Understanding patient-specific trends in costs and healthcare resource utilization (HCRU) surrounding lumbar spine surgery is critically needed to better inform surgical decision making and the development of targeted interventions.
1) Identify subgroups of patients following distinct patterns in direct healthcare payments pre- and postoperatively, 2) determine whether these patterns are associated with patient and surgical factors, and 3) examine whether preoperative payment patterns are related to postoperative payments, healthcare resource utilization (HCRU), and adverse events.
Retrospective analysis of an administrative claims database (IBM Marketscan Research Databases 2007—2015).
Adults undergoing primary single-level decompression surgery for lumbar stenosis (n=12,394).
Direct healthcare payments, HCRU payments (15 categories), 90-day complications and all-cause readmission, 2-year reoperation
Group-based trajectory modeling is an application of finite mixture modeling that is able to identify meaningful subgroups within a population that follow distinct developmental trajectories over time. We used this technique to identify subgroups of patients following distinct profiles in preoperative direct healthcare payments. A separate analysis was performed to identify distinct profiles in payments postoperatively. Patient and surgical factors associated with these payment profiles were assessed with multinomial logistic regression, and associations with adverse events were assessed with risk-adjusted multivariable logistic regression.
We identified 4 preoperative patient payment subgroups following distinct profiles in payments: Pre-Low (5.8% of patients), Pre-Early-Rising (4.8%), Pre-Medium (26.1%), and Pre-High (63.3%). Postoperatively, 3 patient subgroups were identified: Post-Low (8.9%), Post-Medium (29.6%), and Post-High (61.4%). Patients following the higher-cost pre- and postoperative payment profiles were older, more likely female, and had a greater physical and mental comorbidity burden. With each successively higher preoperative payment profile, patients were increasingly likely to have high postoperative payments, use more HCRU (particularly high-cost services such as inpatient admissions, ER, and SNF/IRF care), and experience postoperative adverse events. Following risk adjustment for patient and surgical factors, patients following the Pre-High payment profile had 209.5 (95% CI: 144.2, 309.7; p<.001) fold greater odds for following the Post-High payment profile, 1.8 (1.3, 2.5; p=.003) fold greater odds for 90-day complications, and 1.7 (1.2, 2.6; p=.035) fold greater odds for 2-year reoperation relative to patients following the Pre-Low payment profile.
There are identifiable subgroups of patients who follow distinct profiles in direct healthcare payments surrounding lumbar decompression surgery. These payment profiles are related to patient age, sex, and physical and mental comorbidities. Notably, preoperative payment profiles may provide prognostic value, as they are associated with postoperative costs, HCRU, and adverse events.
III
Gender differences in the decision-making process for undergoing total knee replacement
2022, Patient Education and Counseling
To assess gender differences in the decision-making process for treatment of knee osteoarthritis (OA).
A secondary analysis of a randomized trial was conducted (n = 193). Knowledge of OA and total knee replacement (TKR), decisional conflict, satisfaction with the decision-making process, treatment preference and TKR uptake 6 months later were compared by gender. Multivariate regression models were developed to identify gender-specific predictors.
Women showed less knowledge (MD = −7.68, 95% CI: −13.9, −1.46, p = 0.016), reported less satisfaction (MD = −6.95, 95% CI: −11.7, −2.23, p = 0.004) and gave more importance to avoiding surgery (U = 2.09, p = 0.019). In women, more importance attributed to the time needed to relieve symptoms significantly reduced the odds of surgery (OR = 0.76, p = 0.016).
The provision of information and/or promotion of shared decision-making could be of lower quality in female patients, although other explanations such as differences in information needs or preference for involvement in decision-making cannot be ruled out with the current evidence. Given the study’s limitations, especially regarding the sample size, further confirmation is needed.
A systematic, shared decision-making approach in consultation is needed to avoid potential gender-based biases.

View all citing articles on Scopus

View full text

Gender Differences in Patient Preferences May Underlie Differential Utilization of Elective Surgery

Abstract

Section snippets

Methods

Characteristics of the Subjects (Table 2)

Discussion

Acknowledgements

Sex bias in considering coronary bypass surgery

Ann Intern Med.

Differences in the use of procedures between women and men hospitalized for coronary heart disease

NEJM.

Sex differences in the management of coronary artery disease

NEJM.

Selection of patients for coronary angiography and coronary revascularization early after myocardial infarction: is there evidence for a gender bias?

Ann Intern Med.

Increased mortality of women in coronary artery bypass surgery: evidence for referral bias

Ann Intern Med.

Referral patterns for coronary artery disease treatment: gender bias of good clinical judgement?

Ann Intern Med.

Age, sex, and race inequality in renal transplantation

Arch Intern Med.

Effect of transplantation on the medical end-stage renal disease program:

NEJM