Background – Why an OA Hip and Knee Service?

Osteoarthritis (OA) is a degenerative joint disease and one of the ten most disabling diseases in developed countries. It is estimated that 15% of Australians have arthritis and of these people, 51% have OA (Australian Bureau of Statistics, National Health Survey 2004-05). A major cause of pain, disability and health care use, the costs associated with ongoing care of people with OA are high.

Joint replacement of the hip or knee is not only one of the most cost effective surgical interventions but has a significant impact on improving an individual’s quality of life. Joint replacement is common in Australia with more than 68,000 hip and knee joint replacements performed each year. Timely access to surgery can prevent further worsening of a patient’s condition including overall physical and psychosocial wellbeing.

Number of hip and knee replacement procedures from 1994-1995 to 2005-2006

Waiting for joint replacement – the impact

Long waits:  All patients on an orthopaedic elective surgery waiting list have been assessed by an orthopaedic surgeon and categorised according to the urgency of their condition. In Victorian public hospitals, there are three levels of clinical urgency that currently guide scheduling of patients for elective surgery. These are:

In Victorian public hospitals in 2007-2008, the median waiting time for semi-urgent elective orthopaedic patients was 70 days and 174 days for non-urgent elective orthopaedic patients. A ‘median’ waiting time means that half of the patients wait more than this time.

Patterns of referral to orthopaedic outpatients: The decision to refer patients for outpatient orthopaedic assessment in the public health system is not always straight forward and there is a tendency amongst general practitioners (GPs) to refer patients before they actually require surgery.  This practice is driven by GPs’ concerns about long waiting times for orthopaedic assessment and joint replacement surgery.  GPs may also refer patients to the orthopaedic outpatient clinic to secure access to public allied health services or for a second opinion.

Significant health and economic costs:  There is evidence that waiting for surgery may lead to worsening of a patient’s condition, including their overall physical and psychosocial wellbeing¹, which in turn can impact on surgical outcomes².  This is in part due to inadequate conservative management in the lead-up to surgery³.  There is also evidence of significant cost to the community in terms of direct medical costs and indirect costs such as lost productivity.  Accordingly, Access Economics identifies potential value in managing waiting lists more effectively and for optimising disease management prior to surgery, including self-management.

Opportunities for service improvement

• System challenges: The problems and health impacts associated with long waiting times both for surgery and outpatient consultations reflect a number of problems with service delivery systems, including:
• a lack of standardised care according to best practice guidelines;
• restraints related to specialist and operating theatre resources; and
• inadequate coordination between and within health care services.
  
  
• System improvements: In order to address these issues, effort is required at each stage of patient management, including:
• facilitation of the referral process to orthopaedic outpatients;
• optimisation of patient management in the lead up to orthopaedic consultation and surgery;
• effective prioritisation of surgical service delivery to match patient need;
• appropriate access to surgical services; and
• appropriate access to allied health services.

The Orthopaedic Waiting List (OWL) Project has sought to realise these opportunities for improvement.  It has been conducted as a staged initiative:

Stage I (2004 - 2006):
This involved the development of a tool that prioritises people with hip or knee joint disease for surgery. Download the Stage 1 Report (pfd, 977kb).

Stage II (2006 – 2007):
This involved the development and piloting of a service delivery model that incorporates the prioritisation tool to facilitate optimal management of people who may require JRS.

Stage III (2008-2009):
This involves the extended implementation to a further 10 Victorian hospitals in order to reduce the burden of disease in the Victorian community.

References

1. Sanmartin C. et al., Access to Health Care Services in Canada. Ottawa: Minister of Industry, 2004. 2003. Ostendorf M. et al., Waiting for total hip arthroplasty: avoidable loss in quality time and preventable deterioration. J Arthroplasty, 2004. 19(3): p. 302-9. Fielden J. et al., Waiting for hip arthroplasty: economic costs and outcomes. J Arthroplasty, 2005. 20(8): p. 990-7.
   
   
2. Ackerman IN, Bennell KL. Does pre-operative physiotherapy improve outcomes from lower limb joint replacement surgery? A systematic review. Australian Journal of Physiotherapy, 2004. 50: 25-30.
   
   
3. Osborne RH, Buchbinder R, Ackerman IN. Can a disease-specific education program augment self-management skills and improve Health-Related Quality of Life in people with hip or knee osteoarthritis? BMC Musculoskeletal Disorders, 2006. 7: 90. Ackerman IN, Graves SE, Wicks IP, Bennell, KL & Osborne RH. Severely compromised quality of life in women and those of lower socioeconomic status waiting for joint replacement surgery. Arthritis Care and Research, 2005. 53, 653-8