title: Variability in recommendations for total knee arthroplasty among rheumatologists and orthopedic surgeons.
abstract: OBJECTIVE
  The most rapidly growing population of patients undergoing total knee arthroplasty (TKA) is under the age of 65. The objective of our study was to gain insight into the factors influencing physicians' recommendations for persons in this age group with moderate osteoarthritis (OA).
  
  
  METHODS
  Rheumatologists and orthopedic surgeons attending national meetings were asked to complete 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. We used an experimental 2 × 2 × 2 design to examine the effects of sex, employment status, and severity of radiographic OA on physicians' recommendations. Each physician was asked to rate a single scenario.
  
  
  RESULTS
  The percentage of physicians recommending TKA varied from 30% to 55% for scenarios describing a patient with mild radiographic OA, and from 39% to 71% for scenarios describing a patient with moderate radiographic OA. Surgeons were less likely to recommend TKA for women compared to men of the same age, employment status, symptom severity, and functional status, and radiographs. Rheumatologists practicing in academic settings were more likely to recommend TKA compared to those practicing in nonacademic settings, and American surgeons were more likely to recommend TKA compared to their European counterparts.
  
  
  CONCLUSIONS
  Orthopedic surgeons and rheumatologists vary significantly in their recommendations for patients with moderate knee pain and functional limitations. Both patient and physician characteristics influence physicians' recommendations, and rheumatologists and orthopedic surgeons display different patterns of decision making.
authors.affiliation: From the Yale University School of Medicine, New Haven, Connecticut; Veteran's Administration (VA) Connecticut Healthcare System, West Haven, Connecticut, USA; University of Toronto School of Medicine, Department of Medicine; Women's College Hospital, Toronto, Ontario, Canada.
authors.forename: Liana
authors.initials: L
authors.lastname: Fraenkel
authors.forename: Lisa
authors.initials: L
authors.lastname: Suter
authors.forename: Lawrence
authors.initials: L
authors.lastname: Weis
authors.forename: Gillian A
authors.initials: GA
authors.lastname: Hawker
mesh_terms: D019645:Arthroplasty, Replacement, Knee / Q000706:statistics & numerical data*; D003657:Decision Making; D019538:Health Care Surveys; D006801:Humans; D007719:Knee Joint / Q000000981:diagnostic imaging / Q000601:surgery*; D009985:Orthopedics / Q000706:statistics & numerical data; D020370:Osteoarthritis, Knee / Q000000981:diagnostic imaging / Q000601:surgery*; D010820:Physicians; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011859:Radiography; D012219:Rheumatology / Q000706:statistics & numerical data
keywords: PHYSICIAN BIAS; PRACTICE PATTERNS; TOTAL JOINT ARTHROPLASTY; UNWARRANTED VARIABILITY