Analysis of regional variation in hip and knee joint replacement rates in England using Hospital Episodes Statistics.
ABSTRACT 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.
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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
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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 · 2.44 Impact Factor
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ABSTRACT: International evidence suggests that there are substantial socio-economic inequalities in the delivery of specialist health services, even in the UK and other high-income countries with publicly funded health systems (Goddard and Smith 2001, Dixon et al. 2003, Van Doorslaer, Koolman and Jones 2004, Van Doorslaer et al. 2000). Studies of total hip replacement in the English NHS have yielded particularly striking examples, given that hip replacement is such a common, effective and longestablished health technology. Administrative data show that people living in deprived areas are less likely to receive hip replacement (Chaturvedi and Ben-Shlomo 1995, Dixon et al. 2004) while survey data suggest they may be more likely to need it (Milner et al. 2004). However, previous studies have not examined change in inequality over time. This paper presents evidence on the change in socio-economic inequality in small area use of elective total hip replacement in the English NHS, comparing 1991 with 2001. This was a period of important large-scale health care reform in England, involving at least two significant reforms that might potentially have influenced socio-economic inequality in health care delivery: (1) the introduction and subsequent abolition of the Conservative “internal market” 1991-7, and (2) the introduction in 1995 of a revised NHS resource allocation formula designed to reduce geographical inequalities in health care delivery. Two datasets, for 1991 and 2001, were assembled from routine NHS data sources: Hospital Episode Statistics (HES) on hospital utilisation in England and the corresponding decennial National Censuses in 1991 and 2001. Both datasets contain information on over 8,000 electoral wards in England (over 95% of the total). To improve comparability, a common geography of frozen 1991 wards was adopted. The Townsend deprivation score was employed as an indicator of socio-economic status. Inequality was analysed in two ways. First, for comparability with previous small area studies of hip replacement, by using simple range measures based on indirectly age-sex standardised utilisation ratios (SURs) by deprivation quintile groups. Second, using concentration indices of deprivationrelated inequality in use based on indirectly age-sex standardised utilisation ratios for each individual small area. Each SUR is the observed use divided by the expected use, if each age and sex group in the study population had the same rates of use as the national population.