The Journal of Musculoskeletal Medicine.
Shared Decision Making for Total Joint Replacement: The Physician’s Role
Addressing the 10 questions patients most frequently ask
By YVONNE C. LEE, MD and JEFFREY N. KATZ, MD |
October 31, 2008
Dr Lee is a rheumatology fellow at Brigham
and Women's Hospital in Boston. Dr Katz is
associate professor of medicine and orthopedic
surgery at Harvard Medical School, director
of the Robert Brigham Arthritis and
Musculoskeletal Clinical Research Center,
and director of the Orthopedic and Arthritis
Center for Outcomes Research at Brigham
and Women's Hospital in Boston. For this article,
the authors have updated their discussion
of decision making for joint replacement
that first appeared in 2007 in The
Journal of Musculoskeletal Medicine.
Several studies have assessed racial, ethnic, and sex disparities in TJR.40 Most of these studies have focused on differences in priorities and expectations between groups of patients. For example, women are less likely to undergo TJR than men. Focus groups have shown that women are more concerned than men about becoming a burden to their family after surgery.41 Therefore, they may place greater emphasis on healing time, length of hospitalization stay, and need for inpatient rehabilitation. They also may be more risk-averse.
Similarly, African Americans are less likely to have TJR than whites. Low rates of TJR among African Americans may be the result of a combination of low expectations for TJR and high expectations for alternative therapies. Many African Americans view prayer as a useful method of managing arthritis and, among those who believe in prayer, fewer view surgery as an acceptable alternative.42
Compared with white men who have OA, African American men with OA have lower expectations for the outcomes of TJR, independent of socioeconomic variables, literacy, and social support.43 Interventions such as an educational videotape and tailored decisionmaking may improve expectations among African American men,44 but it is not clear whether these interventions improve TJR rates.
These examples illustrate the complexity of decision making with regard to TJR and other elective procedures.The decision to undergo TJR requires comprehensive, effective communication between physician and patient via a shared decision-making process. Physicians must understand both the medical aspects of TJR and the social and cultural factors that influence their patients' preferences.
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