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Features of male versus female patients undergoing surgery for osteoarthritiscomment on two recent articles.

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Number 3, March 1995, pp 448-449
0 1995, American College of Rheumatology
Features of male versus female patients undergoing
surgery for osteoarthritis: comment on two recent
To the Editor:
We are writing to reconcile the seemingly contradictory findings of two recent articles published by our groups
in Arthritis and Rheumatism, on differences between men
and women undergoing surgery for osteoarthritis (OA) (1,2).
The Brigham and Women’s ]Hospital study showed that
women reported substantially, significantly worse functional
status than men at the time of total hip and knee arthroplasty
and of laminectomy for degenerative lumbar spinal stenosis.
Women undergoing total knee replacement also had more
limited range of knee motion than men, while there were no
gender differences in physical examination findings in the
laminectomy and hip arthroplasty cohorts. Radiographs
were not evaluated.
The Mayo Clinic study also revealed a trend (of
borderline statistical significance) toward worse selfreported preoperative functional status in women. However,
men had significantly more severe radiographic hip OA and
more limited range of hip motion than women, although the
latter difference did not reach statistical significance. Since
women were no worse than men on 17 of 19 clinical variables
and women had less severe radiographic involvement, the
Mayo group reported that women did not have more severe
OA than men prior to hip arthroplasty.
The two studies difixed methodologically. The
Brigham and Women’s Hospital study was conducted in
referral centers; the Mayo Clinic study was population
based. The Brigham and Women’s Hospital study had detailed functional status information obtained with validated
instruments, but limited data on objective impairment; the
Mayo Clinic group had access to a broader array of impairment data (physical and radiographic), but limited information on functional status (single unscaled items were abstracted from medical records). In the Brigham and
Women’s Hospital study, preoperative functional status data
were obtained by patient recall 6 months after surgery for
OA of the hip or knee, while data on lumbar spinal stenosis
were collected prospectively, all of the Mayo data were
obtained prospectively. It is difficult to determine whether
and how much these methodologic differences influenced the
principal findings of the studies. In particular, we do not
know whether determinants of the decision to undergo
surgery are the same for community patients and those who
travel to a tertiary referral center.
Despite these differences, similar themes emerged
from the two studies. The Brigham and Women’s Hospital
study showed that women hiad worse self-reported functional status than men; the Mayo Clinic findings lend modest
support to this conclusion. Tlhe Mayo Clinic study showed
that women had less severe radiographic involvement than
men and similar physical exatmination features of hip OA;
the Brigham and Women’s Hospital data support this result.
We suggest that the difiicult quandary posed by these
data is the issue of which indicator of disease severity-selfreported functional status or objective measures of impairment such as radiographic appearance or range of motionshould be used in questions regarding differential utilization
of health resources. In OA of the hip, the correlation
between passive flexion and self-reported physical functional status is -0.05 (2), indicating that these measures of
disease impact are virtually independent. While radiographs
and range of motion are “objective,” the decision to undergo elective surgery is driven primarily by an individual’s
reported functional limitations, rather than objective impairments (3,4).
The discordance between self-report and objective
measures of impairment underlies the question of whether
there are indeed gender differences in utilization of major
surgery for OA: Women appear to be worse on self-report
measures of functional status, but not on measures of
objective impairment. The interplay between objective and
self-reported findings is a fruitful area for further research,
with policy implications that extend far beyond gender
differences in the treatment of OA.
Jeffrey N. Katz, MD, MS
Matthew H. Liang, MD, MPH
Robert Brigham Multipurpose Arthritis and
Musculoskeletal Disease Center
Brigham and Women’s Hospital
Boston, MA
Sherine E. Gabriel, MD, MSc
Mayo Clinic and Foundation
Rochester, M N
Paul D. Cleary, PhD
Harvard Medical School
Boston, MA
1. Gabriel SE, Wenger DE, Ilstrup DM, Lewallen DG, Melton LJ
111: Lack of evidence for gender bias in the utilization of total hip
arthroplasty among Olmsted County, Minnesota residents with
osteoarthritis. Arthritis Rheum 37: 1171-1 176, 1994
2. Katz JN, Wright EA, Guadagnoli E, Liang MH, Karlson EW,
Cleary PD: Differences between men and women undergoing
major orthopedic surgery for osteoarthritis. Arthritis Rheum
37:687494, 1994
3. Hams WH, Sledge CB: Total hip and total knee replacement
(first of two parts). N Engl J Med 323:725-731, 1990
4. Harris WH, Sledge CB: Total hip and total knee replacement
(second of two parts). N Engl J Med 323:801-807, 1990
Diagnosis of arthritis by primary care providers
versus rheumatologists: comment on the article by
Chan et a1
To the Editor:
Chan et a1 demonstrate quite clearly that there are
long lag times in the diagnosis of rheumatoid arthritis by
primary care providers in a managed care setting (Chan
K-WA, Felson D, Yood RA, Walker AM: The lag time
between onset of symptoms and diagnosis of rheumatoid
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