WHEN DO PHYSICIANS RECOMMEND JOINT REPLACEMENT FOR PATIENTS WITH MODERATE DISEASE?

Purpose: Rates of total knee arthroplasty (TKA) are increasing among all age groups. The most rapidly growing population of patients undergoing TKA are those under the age of 65. This reason for this increasing prevalence is unclear. While physicians' recommendations regarding use of TKA are likely to be fairly uniform for patients with severe OA, little is known regarding physicians' decision-making for younger patients with less severe arthritis. The objective of this study was to gain insight into the factors influencing physicians' recommendations for younger persons with moderate OA using an experimental 2x2x2 design.

Methods: A convenience sample of rheumatologists and orthopedic surgeons, recruited at their respective national meetings, completed a survey including a standardized scenario of a 62 year old person with knee OA who has moderate knee pain limiting strenuous activity despite medical management. The scenarios varied on patient gender, employment status (business manager vs retired), and x-ray (mild vs moderate OA). Each subject rated their recommendation for a single scenario (distributed randomly) on a 7-point scale. Recommendation was treated as a dichotomous variable: For vs Against TKA.

Results: 406 surgeons [mean age (SD) = 49 (10), 18% female] and 494 rheumatologists; [mean age (SD) = 48 (10), 44% female] participated. Overall, 51% of both surgeons and rheumatologists recommended TKA. As expected, both groups recommended TKA more frequently for scenarios including more severe radiographic OA. However, this feature had a greater influence among rheumatologists than orthopedic surgeons. Orthopedic surgeons were more likely to recommend TKA for male vs female patients. Whereas, rheumatologists were more likely to recommend referral for TKA for retired vs working patients. Younger physicians, regardless of specialty, were more likely to recommend TKA (p <0.05). There was no difference among European vs US rheumatologists; however, American surgeons were more likely to recommend TKA compared to their European counterparts (52% vs 34%, p=0.007).

Conclusions: Physicians recommendations for TKA vary significantly for younger patients with moderate OA. Recommendations are influenced by both physician and patient characteristics.