abstract: 'Background: Documented age, gender, race and socio-economic disparities

  in total joint arthroplasty (TJA), suggest that those who need the

  surgery may not receive it, and present a challenge to explain the

  causes of unmet need. It is not clear whether doctors limit treatment

  opportunities to patients, nor is it known the effect that patient

  beliefs and expectations about the operation, including their paid work

  status and retirement plans, have on the decision to undergo TJA.

  Identifying socio-economic and other determinants of demand would inform

  the design of effective and efficient health policy. This review was

  conducted to identify the factors that lead patients in need to undergo

  TJA.

  Methods: An electronic search of the Embase and Medline (Ovid)

  bibliographic databases conducted in September 2011 identified studies

  in the English language that reported on factors driving patients in

  need of hip or knee replacement to undergo surgery. The review included

  reports of elective surgery rates in eligible patients or, controlling

  for disease severity, in general subjects, and stated clinical experts''

  and patients'' opinions on suitability for or willingness to undergo TJA.

  Quantitative and qualitative studies were reviewed, but quantitative

  studies involving fewer than 20 subjects were excluded. The quality of

  individual studies was assessed on the basis of study design (i.e.,

  prospective versus retrospective), reporting of attrition, adjustment

  for and report of confounding effects, and reported measures of need

  (self-reported versus doctor-assessed). Reported estimates of effect on

  the probability of surgery from analyses adjusting for confounders were

  summarised in narrative form and synthesised in odds ratio (OR) forest

  plots for individual determinants.

  Results: The review included 26 quantitative studies-23 on individuals''

  decisions or views on having the operation and three about health

  professionals'' opinions-and 10 qualitative studies. Ethnic and racial

  disparities in TJA use are associated with socio-economic access factors

  and expectations about the process and outcomes of surgery. In the

  United States, health insurance coverage affects demand, including that

  from the Medicare population, for whom having supplemental Medicaid

  coverage increases the likelihood of undergoing TJA. Patients with

  post-secondary education are more likely to demand hip or knee surgery

  than those without it (range of OR 0.87-2.38). Women are as willing to

  undergo surgery as men, but they are less likely to be offered surgery

  by specialists than men with the same need. There is considerable

  variation in patient demand with age, with distinct patterns for hip and

  knee. Paid employment appears to increase the chances of undergoing

  surgery, but no study was found that investigated the relationship

  between retirement plans and demand for TJA. There is evidence of

  substantial geographical variation in access to joint replacement within

  the territory covered by a public national health system, which is

  unlikely to be explained by differences in preference or unmeasured need

  alone. The literature tends to focus on associations, rather than

  testing of causal relationships, and is insufficient to assess the

  relative importance of determinants.

  Conclusions: Patients'' use of hip and knee replacement is a function of

  their socio-economic circumstances, which reinforce disparities by

  gender and race originating in the doctor-patient interaction.

  Willingness to undergo surgery declines steeply after the age of

  retirement, at the time some eligible patients may lower their

  expectations of health status achievement. There is some evidence that

  paid employment independently increases the likelihood of operation. The

  relative contribution of variations in surgical decision making to

  differential access across regions within countries deserves further

  research that controls for clinical need and patient lifestyle

  preferences, including retirement decisions. Evidence on this question

  will become increasingly relevant for service planning and policy design

  in societies with ageing populations.'
affiliation: 'Mota, REM (Corresponding Author), Univ Exeter, Inst Hlth Serv Res, Veysey
  Bldg,Salmon Pool Lane, Exeter EX2 4SG, Devon, England.

  Mota, Ruben E. Mujica, Univ Exeter, Inst Hlth Serv Res, Exeter EX2 4SG, Devon, England.

  Tarricone, Rosanna; Ciani, Oriana, Univ Bocconi, Ctr Res Healthcare Management,
  I-20136 Milan, Italy.

  Bridges, John F. P., Johns Hopkins Bloomberg Sch Publ Hlth, Baltimore, MD 21205
  USA.

  Drummond, Mike, Univ York, Ctr Hlth Econ, York YO10 5DD, N Yorkshire, England.'
article-number: '225'
author: Mota, Ruben E. Mujica and Tarricone, Rosanna and Ciani, Oriana and Bridges,
  John F. P. and Drummond, Mike
author-email: r.e.mujica-mota@exeter.ac.uk
author_list:
- family: Mota
  given: Ruben E. Mujica
- family: Tarricone
  given: Rosanna
- family: Ciani
  given: Oriana
- family: Bridges
  given: John F. P.
- family: Drummond
  given: Mike
da: '2023-09-28'
doi: 10.1186/1472-6963-12-225
eissn: 1472-6963
files: []
journal: BMC HEALTH SERVICES RESEARCH
keywords: 'Orthopaedic implant; Arthroplasty; Hip; Knee; Demand; Need; Equity;

  Preferences; Patient selection; Osteoarthritis; Decision to operate;

  Socio-economic disparities; Total joint replacement'
keywords-plus: 'QUALITY-OF-LIFE; JOINT REPLACEMENT SURGERY; WILLINGNESS-TO-PAY; AGED
  55

  YEARS; DECISION-MAKING; ORTHOPEDIC SURGEONS; PATIENT PREFERENCES;

  PRIMARY-CARE; POPULATION REQUIREMENT; SOCIOECONOMIC-STATUS'
language: English
month: JUL 30
number-of-cited-references: '109'
orcid-numbers: 'Ciani, Oriana/0000-0002-3607-0508

  Mujica-Mota, Ruben/0000-0002-7430-2744

  TARRICONE, ROSANNA/0000-0002-2009-9357'
papis_id: b783b371f4d2e82b7092127ebf1b9828
ref: Mota2012determinantsdemand
researcherid-numbers: 'Ciani, Oriana/D-1455-2015

  '
tags:
- review
times-cited: '95'
title: 'Determinants of demand for total hip and knee arthroplasty: a systematic literature
  review'
type: Review
unique-id: WOS:000310348400001
usage-count-last-180-days: '2'
usage-count-since-2013: '48'
volume: '12'
web-of-science-categories: Health Care Sciences \& Services
year: '2012'