Patient Complications After Total Joint Arthroplasty: Does Surgeon Gender Matter?

Talia Ruth Chapman, MD; Benjamin Zmistowski, MD; Kaitlyn Votta, BS; Ayesha Abdeen, MD; James J. Purtill, MD; Antonia F. Chen, MD, MBA

Disclosures

J Am Acad Orthop Surg. 2020;28(22):937-944. 

In This Article

Discussion

Overall, this analysis revealed that female surgeons performing TJA in this data set made up a small percentage of the total surgeons and the volume of procedures that were performed. Only 2% of arthroplasty surgeons were women compared with 13% in the general orthopaedic workforce.[3] Despite their lower volume and younger practices, there were limited differences in the ACRs of total hip and knee arthroplasty performed by male and female orthopaedic surgeons before multivariate analysis. Multivariate analysis confirmed that surgeon gender does not play a significant role in predicting patient outcomes when adjusting for case volume and years since medical school graduation.

Little is known about the influence of surgeon gender on complications after surgery, and to our knowledge, this is the first study examining that question in the field of orthopaedic surgery. One previous study examined complications based on surgeon gender in the field of general surgery. The investigators matched patients who underwent one of 25 surgical procedures performed by a female surgeon with patients undergoing the same operation by a male surgeon. After controlling for patient demographics, surgeon, and hospital characteristics, patients treated by female surgeons had a statistically significant decrease in 30-day mortality and similar surgical outcomes compared with those treated by a male surgeon.[6] Male surgeons in that cohort did have a higher volume of cases, which is consistent with our study. In addition, when breaking down the procedures by subspecialty, no significant difference was observed in adverse events between male and female orthopaedic surgeons.

Recently, one study found that elderly hospitalized patients treated by female internists have lower mortality and readmissions compared with those cared for by male internists.[5] The authors hypothesize that differences in practice patterns between male and female physicians may be at the root of this difference and may have important clinical implications for patient outcomes. The authors cite previous studies, which have shown that female physicians are more likely to adhere to clinical guidelines in treating diabetes and cardiac disease, more likely to provide preventive care, and use more patient-centered communication as potential reasons for the differences seen.[21–29]

The technical skill of a surgeon may also play a role in patient outcomes in orthopaedics. There is little research on the differences in learning styles, acquisition of skills, or outcomes for female and male surgeons; however, one systematic review concluded that differences surgical skills between male and female residents were negligible.[30] Another study evaluated 25 surgical residents performing on a virtual reality computer simulator for laparoscopic surgery. They found that men completed the tasks in less time than women, but there was no statistical difference between the genders in the number of errors and unnecessary movements.[31]

Despite increasing diversity, the field of orthopaedic surgery remains a male-dominated one, particularly in the subspecialty of hip and knee joint replacement. Diversity of orthopaedic surgeons has the potential to improve patient care. Studies have shown that patients who identify with their physicians have quicker recovery rates and better adherence.[32–34] This emphasizes a pertinent question: what can we do to make patients more comfortable with their orthopaedic surgeons? In one study of plastic surgery patients, 200 female patients were asked if they preferred a male or female surgeon. Preference for a female surgeon was significant.[35] This is especially pertinent because there is a higher proportion of female patients undergoing TJA. In 2014, 127 of 100,000 women underwent TKA compared with only 106 men. In addition, 206 of 100,000 women underwent THA compared with only 165 men. These numbers are expected to increase from 71% to 147% by 2030.[36]

The limitations of this study, however, must not be overlooked. This analysis relied on billing data for its assessment of complications. This markedly limits the potential outcomes that may be assessed to those requiring acute postoperative readmission and/or revision surgery. Although great care was taken by those evaluating these "complications" to correctly categorize them, this was not done by chart review and may not accurately represent the cause for further care in specific cases. In addition, the primary outcome measure of this study was the ACR measured by the large data set, which only captured readmissions or mortality because of the index procedure within the first 30 days. This outcome measure does not capture complications outside of those 30 days and does not evaluate long-term outcomes such as overall function and pain, mobility, range of motion, or patient-reported outcomes.

To this end, there is notable concern regarding the publication of surgeon-specific outcomes as a potential misrepresentation of that surgeon's delivery of care. For these purposes, the authors do not support nor condemn the public availability of these outcome measures. It is argued, rather, that although the individual complication rates reported may not be an accurate representation of that surgeon because of small case volumes and inability to adjust for case difficulty or region-specific practices, on aggregate, we would expect no bias to be introduced by sex and therefore accept any differences in outcome measures realized in this analysis. Owing to the limitations of this database, these findings may not be generalizable outside the Medicare cohort and it is not possible to account for longer term outcome measures. Outcomes such as infection rate, early revision rate, and patient functional scores may be more valuable outcome measures in the long term. However, this does not detract from the importance of containing costs and providing quality care in the acute postoperative period. In addition, it is possible that the exclusion of very low arthroplasty volume surgeons could create selection bias. However, the intention of this analysis was limited to the impact of surgeon gender on complications after arthroplasty by surgeons who consistently perform these procedures. It is well-known that volume predicts quality;[10] the enforced threshold by the data set excluded low-volume surgeons who were not of interest. Although imperfect, this methodology is impartial and provides an early step in understanding the implications of an orthopaedic surgeon's gender on patient outcomes after TJA.

Ultimately, although the differences in complicate rates after TJR surgery between male and female surgeons were not notable, this analysis did confirm the dearth of female orthopaedic arthroplasty surgeons in this cohort. Further research is necessary to understand what variables such as clinical acumen, technical skills, or risk-taking behavior, might lead to differences in outcomes or practices between orthopaedic surgeons of different genders.

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