PCPs waffle in referrals for total joint replacement



PARIS – Primary care physicians are only moderately confident about which patients to refer for total hip or knee replacement, according to cross-sectional survey of 218 physicians.

One-quarter (27.4%) were unsure about the risks of total joint arthroplasty (TJA), and 44.3% reported they were discouraged from referring patients for TJA because of a lack of clarity about surgical indications.

When asked how confident they were in deciding which patients should be referred to orthopedic surgery for consideration of hip or knee replacement, the average response was 6.9 on a 10-point scale from "not at all" to "highly confident," indicating a moderate level of confidence, Esther* Waugh, Ph.D., reported at the World Congress on Osteoarthritis.

"The results suggest the need for increased guidance for primary care physicians regarding which patient, and when, total joint arthroplasty should be considered," she concluded. "While lack of confidence does not necessarily equate with decreased competence, additional clarity may result in enhanced physician confidence, improved decision making, and ultimately better surgical outcomes through better patient selection of appropriate candidates."

A total of 376 primary care physicians (PCPs) were recruited from among those providing care to participants of an established community cohort with symptomatic hip or knee osteoarthritis (OA) in Ontario, Canada, with 218 (58%) completing the standardized questionnaire by mail or online.

One-third reported seeing more than 10 moderate to severe hip/knee OA patients in the previous 2 weeks.

Most had been in practice for more than 15 years (77%), were in group practice (63%), and were older than age 50 years (65%). One-third practiced in a rural location, and 31% had more than 10 TJA referrals per year.

Interestingly, total hip and total knee arthroplasty was perceived as "very effective" by 53% and 40% of physicians, respectively, according to Dr. Waugh of the physical therapy department at the University of Toronto.

Still, TJA was viewed as carrying high risks of death by 11.3%, of complications by 35%, and need for revision surgery by 12.3%.

Lower confidence in referring patients for TJA was independently associated with lack of clarity about surgical indications (P less than .0001; parameter estimate, –1.02) and female sex (P = .02; parameter estimate, –0.54), in multiple linear regression analysis.

Both factors were associated with fewer years of practice, she noted. Female physicians were significantly more likely to report fewer years of practice (P less than .0001), fewer OA patients (P = .0004), practicing in a group practice (P = .003), urban practice location (P = .003), and being unsure about risks (P = .02).

Confidence was not associated with uncertainty of TJA risks, volume of OA patients in the prior 2 weeks, group practice, years of practice, or rural practice setting, Dr. Waugh reported at the meeting, sponsored by the Osteoarthritis Research Society International.

Prior research by the University of Toronto team demonstrated underuse of total joint arthroplasty, but concerns have recently been raised regarding possible overuse, particularly in younger patients. In Canada, PCPs are responsible for referrals to orthopedic surgery for TJA. Thus, "inappropriate under- or overuse of TJA may be a consequence of uncertainty among PCPs about indications for TJA," the authors noted in the poster presentation

Conflict of interest disclosures were not available at press time.

*Correction, 5/8/2014: An earlier version of this story misspelled Dr. Esther Waugh's name.

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