"Even in a situation where there is universal access to health care, people with lower incomes and/or less education are much more likely to be living with disabling hip and knee arthritis, possibly because they have less access to care," says Dr. Gilllian Hawker, associate professor in medicine and health policy, management and evaluation, and director of the clinical epidemiology program at U of T. Hawker, who is also a rheumatologist at Sunnybrook and Women's College Health Sciences Centre, is lead author of a paper in the December issue of Arthritis and Rheumatism.
"In quantifying the potential need for joint replacement surgery, people with low education or incomes were twice as likely to have severe hip or knee arthritis, yet only half as likely to be on a waiting list for joint replacement surgery, compared to wealthier and better educated people. This, despite the fact that the former were not more likely to have other medical problems that precluded them from being surgical candidates and were just as willing as the latter to consider surgery as treatment for their arthritis."
Hawker and her co-researchers surveyed over 48,000 people aged 55 and over in two areas of Ontario - East York and Oxford County - from 1996 to 1998. They identified 3,307 people with moderate to severe hip or knee problems and have been following that research group ever since. The individuals were asked about income and education levels, arthritis severity, day-to-day ability to function and other medical conditions that would be considered contraindications to surgery. The researchers also conducted interviews with a portion of the group to determine their willingness to consider hip or knee replacement surgery.
In analyzing their data, they discovered that 45 per cent of individuals with less than high school education met their criteria as ideal candidates for joint replacement surgery, compared with only 30 per cent of individuals with post-secondary education. However, among those ideal candidates, 12 per cent in the higher income category were on waiting lists for this surgery compared to only five per cent in the lower income brackets. They also found women were half as likely as men to have ever discussed joint replacement with their doctors. When the researchers took into account the women's socio-economic status, they found those with low income to be 80 per cent less likely than the rest of the research group to have ever discussed joint replacement with their doctors.
"If you've got low education and low income, it doesn't matter whether you're a woman or a man, you've got high need and low access," says Hawker. "However, if you've got high income or are well educated, then gender matters. Women in higher socio-economic categories have less access to joint replacement surgery than their male counterparts.
"I'm not saying that there are biases per se, although there may be. But people may communicate differently with their physicians depending on their gender and socio-economic status. This, in turn, may very well affect whether or not they receive certain treatment options like hip and knee replacement surgery."
Hawker says she and her co-researchers are nearing completion of the second phase of their work - five-year follow-up of their research subjects to identify factors that determine access to joint replacement surgery. "There's a huge number of people out there with unmet need for joint replacement who are not on waiting lists. Most have never discussed joint replacement with their doctors. We need to find out why. Our current study suggests that we cannot explain the lower rates of use of hip and knee replacement surgery among those with lower socio-economic status on the basis of their being less willing to consider this treatment or are more likely to have contraindications to having the surgery."
Other members of the research team include: Dr. James Wright of The Hospital for Sick Children and U of T's departments of surgery, public health sciences and health policy, management and evaluation; Dr. Richard Glazier of St. Michael's Hospital, the Arthritis Community Research and Evaluation Unit, the Institute for Clinical Evaluative Sciences and public health sciences at U of T; Professor Peter Coyte of health policy, management and evaluation at U of T and the Institute for Clinical Evaluative Sciences; Dr. Bart Harvey of the Community Medicine Residency Program at U of T; Professor Ivan Williams of the Institute for Clinical Evaluative Sciences and the Toronto Rehabilitation Research Institute; and Professor Elizabeth Badley of the Arthritis Community Research and Evaluation Unit.
The research was supported by the Canadian Institutes for Health Research, The Arthritis Society of Canada, Physicians' Services Incorporated Foundation, the Canadian Orthopaedic Foundation and the University of Toronto Dean's Fund.
CONTACT:
Dr. Gillian Hawker
Department of Health Policy, Management and Evaluation
416-323-7722
g.hawker@utoronto.ca
Janet Wong
U of T Public Affairs
416-978-5949
jf.wong@utoronto.ca
Journal
Arthritis & Rheumatism