Total hip and knee joint replacements are effective interventions for people with severe arthritis, and demand for these operations appears to be increasing as our population ages. This study explores regional variations in health care and inequalities in the provision of these expensive interventions, which are high on the UK Government's health agenda.
The Hospital Episode Statistics (HES) for England were analysed. The HES database holds information on patients who are admitted to National Health Service (NHS) hospitals in England.
Age-standardized procedure rates were calculated using 5-year age groups with the English mid-year population of 2000 as the reference. Univariate associations between age-standardized operation rates and regional characteristics were assessed using Pearson's correlation coefficient.
Age and sex-standardized surgery rates vary by 25-30%. For both hip and knee replacement, rates are highest in the South West and Midlands and lowest in the North West, South East and London regions. In the case of knee replacement, there are also marked differences in the sex ratios between regions. The variable that explained most variation in hip replacement rates was the proportion of older people in the region. In the case of knee replacement, the number of NHS centres offering surgery in the region was the main explanatory variable, with regions with fewer centres having the highest provision rates.
These data can help to inform planning of services. They suggest that there may be inequities as well as inequalities in the provision of primary joint replacement surgery in England.
"Hence rates of publicly funded surgery leave considerable unmet need in New Zealand, even in better served areas. Differences in publicly funded surgery rates across New Zealand were larger than found in England (25–30%) (Dixon et al., 2006). The wide variation in surgery rates across New Zealand could partly be because of the small population base in some DHB regions. "
[Show abstract][Hide abstract] ABSTRACT: New Zealand has a two-tier health system with elective surgery provided by both publicly funded state hospitals and by private hospitals. Issues of equity should be considered across such systems-where the better off can access surgery in private hospitals regardless of relative clinical need. This study evaluated equity of provision of surgery after the introduction of a prioritization system to manage access. Data for people receiving publicly funded elective joint replacement, prostatectomy or cataract surgery between 2000 and 2005 were obtained, as well as most recent data for people receiving privately funded surgery (2001 and 2002). Denominators were derived from the 2001 census for the population of District Health Board regions. NZDep2001, a small-area deprivation index, was used to identify people in poorest deciles. Despite the introduction of a prioritization system aimed at increased equity and fairness, the provision of elective surgery remains inequitable geographically. High private provision was not associated with better access to publicly funded surgery. Moreover, the argument that private provision for the well off reduces the burden on the public system allowing better access for the poor was not supported. Consequences of two-tier health systems, as in New Zealand, need more investigation and public discussion.
International Journal of Health Planning and Management 04/2009; 24(2):147-60. DOI:10.1002/hpm.978 · 0.97 Impact Factor
"Admission rates and the respective rates for orthopedic surgeries have been reported in multiple countries: USA (Deyo and Mirza, 2006; Keller et al., 1990; Weinstein et al., 2004), Spain (Bernal Enrique et al., 2005), England (Dixon et al., 2006), Canada (Blais, 1993; Coyte et al., 1996; Gentleman et al., 1996), Ireland (Willis et al., 2000), Finland (Keskimaki et al., 1994) and Denmark (Pedersen et al., 2005). However, only a few comparative studies across countries exist, mostly due to a mismatch between data recording procedures and different patient populations (Merx et al., 2003) such as the Medicare beneficiaries in US studies (Vitale et al., 1999; Weinstein and Birkmeyer, 1996; Sporer et al., 2006). "
[Show abstract][Hide abstract] ABSTRACT: The study systematically describes the frequency and geographic variability of major surgical interventions for musculoskeletal disorders in Switzerland. Age- and sex-standardized rates for joint replacements, arthroscopies, spine surgery and hip fracture repair were calculated for hospital service regions. Various statistical analyses were used to measure the extent of variation. The authors argue that the surgery of hip fractures can be used as index surgery in the context of analyzing variations in orthopedic surgery. Temporal trends imply that patient demand and supply factors related to clinical ambiguity and non-medical incentives of providers are far more important components leading to increased use than the sole effect of an aging population.
Health & Place 02/2009; 15(3):761-8. DOI:10.1016/j.healthplace.2008.12.009 · 2.81 Impact Factor
"Although evidence-based guidelines recommend exercise, education, and medication , management of chronic knee pain usually involves palliative medication, in spite of its potential risks and costs [4,5]. Fewer people are referred to physiotherapy  and only people with severe, disabling pain are referred for total knee replacement (TKR) surgery . "
[Show abstract][Hide abstract] ABSTRACT: A range of interventions exist for the management of knee pain, but patient preferences for treatment are not clear. In this study the management received by people with chronic knee pain, their management preferences and reasons for these preferences were recorded.
At baseline assessment of a clinical trial of rehabilitation for chronic knee pain, 415 participants were asked about their i) previous management, ii) preferred treatment, if any, iii) whether they would undergo knee surgery and iv) reasons for their preferences.
Previous management--Medication was the most common treatment, followed by physiotherapy, 39 participants had received no treatment. Preferences--166 patients expressed no treatment preference. Of those who expressed a preference the most popular option was physiotherapy, whilst not having surgery was the third most frequent response. The most common reason for preferring physiotherapy and not wanting surgery was prior experience.Willingness to accept surgery--390 participants were not waiting for knee replacement surgery, and overall 81% would not accept surgery if offered, usually because pain was not perceived to be severe enough to warrant surgery.
Most chronic knee pain is managed with medication despite concerns about safety, efficacy and cost, management guidelines recommendations and people's management preferences. Previous experience and perceptions of need were major determinants of people's preferences, but many people were unaware of management options. Appreciating patient preferences and provision of more information about management options are important in facilitating informed patient/clinician discussion and agreement.
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