Abstract

There are more total hip and knee replacement surgeries being performed on Ontarians each year than ever before. The Ministry of Health and Long-Term Care (MOHLTC) has made it a priority program and has increased funding to meet growing demand. But despite the increase in the number of surgeries performed, waiting lists keep getting longer. These procedures are the definitive treatments for reducing pain and disability, and with an aging population, the number of people requiring surgery is expected to rise even higher. Our research has shown that over a six-year period, total hip replacements increased by 22% while the total number of knee procedures skyrocketed by 52%. Waiting lists, however, did not keep pace. In 1993, the median waiting time for total hip replacements was 16 weeks; in 1998 it had increased to 20 weeks. The median waiting times for total knee replacement increased from 20 weeks in 1993 to 26 weeks in 1998.

In an effort to address this growing issue, the MOHLTC asked ICES to lead a Consensus Group to make recommendations on an information system for managing waiting lists for total joint replacements. The panel comprised a broad range of clinical experts including orthopedic surgeons, rheumatologists and family physicians, as well as stakeholder organizations and the Canadian Joint Registry Initiative. The final results of this group were published in the ICES Technical Report, Urgency Rating, Waiting List Management and Patient Outcomes Monitoring for Primary Hip/Knee Joint Replacement. (#00-04-TR). (See: www.ices.on.ca)

The primary recommendation was the creation of an information infrastructure that would provide the Ministry with information on urgency for surgery, waiting times and patient outcomes. The system would help in the management of waiting lists and ensure the most severe cases on the list would be given first priority for surgery. In its report, the ICES Consensus Group recommends that the Ontario Joint Replacement Registry (created in March 2000 with funding from MOHLTC) establish waiting lists based upon the Western Ontario McMaster Osteoarthritis Index (WOMAC). This tool focuses on patient self-report of pain, stiffness and function as it relates to their hip and knee. The Consensus Group proposed that information on each patient be tracked from the time an orthopedic surgeon recommends the procedure and the patient completes the WOMAC questionnaire, right through to an assessment 12 months after the surgery.

Plans are now under way to implement the recommendations into the Ontario Joint Replacement Registry in an incremental fashion, starting with a pilot study in Southwestern Ontario during the first part of 2001. The ultimate goal: to reduce patients' waiting times for consultation and surgery, linked with clinical severity, and to improve patient outcomes in terms of reduction of pain and enhanced function.

Another key goal is to monitor joint replacement devices in order to improve quality of care. Recommendations from the pilot project will help to evaluate patients' clinical status and will be used to further define methods to better manage waiting lists - based on need rather than "first come, first serve" as it is now. Inclusion of the recommendations into the joint registry will make the registry the most thorough and complete patient-based registry for joint replacement in the world.

The Consensus Group agreed that the success of this initiative requires strategic provision and allocation of resources. The MOHLTC must commit sufficient funds and collaborate with hospitals to reallocate resources. As well, orthopedic surgeons will have to make adjustments to their workloads in order to perform the additional procedures.

About the Author

J. Ivan (Jack) Williams, PhD, is a Senior Scientist at ICES and Vice-President of Research at the Toronto Rehabilitation Institute.Nizar Mahomed, MD, is an Adjunct Scientist at ICES, and Assistant Professor in the Orthopedic Surgery Division at the Toronto Western Hospital. Kathy Knowles Chapeskie is former manager of the research transfer unit at ICES.

For more information, contact: Judy Hodgson at 416-480-4055,
ext. 3781