Waiting times and patient perspectives for total hip and knee arthroplasty in rural and urban Ontario ===================================================================================================== * Matthew G. Snider * Steven J. MacDonald * Ralph Pototschnik ## Abstract **Background:** The demand for total hip and total knee arthroplasties is increasing as are the waiting times for these procedures. Because of the differences between rural and urban areas in terms of the provision of arthroplasty services and between the 2 patient groups, patient perspectives of waiting times may also be different. **Methods:** To compare waiting times for initial orthopedic consultation and total hip and knee arthroplasties in rural Ontario (Stratford) and in urban Ontario (London), and to compare patient perspectives of these waiting times, we mailed a survey to all 260 patients who underwent total hip or total knee arthroplasty between June 1, 2000, and June 1, 2001. The survey asked for the length of wait for consultation and for surgery, acceptability of waiting time for surgery, the effect of waiting on health and what an acceptable waiting time would be. Of the 260 surveys mailed 202 (78%) were returned. We reviewed the charts of the respondents to determine the actual waiting times. **Results:** The actual waiting times (mean [and standard deviation]) for initial consultation were significantly (*p* < 0.001) shorter in the rural (RUR) group (1.10 [0.53] mo) than the urban (URB) group (3.40 [1.34] mo). There was no significant difference in waiting times for surgery between RUR (8.45 [3.32] mo) and URB (9.32 [3.61] mo) groups. Surgical waiting times for both groups showed that 56% of all the patients had to wait longer than 9 months from the date surgery was recommended. Perceived waiting times for consultation were found to be 56.9% longer (*p* < 0.001) than the actual waiting times, but there was no significant difference between perceived and actual waiting times for surgery (*p* = 0.40). Fifty percent of the patients stated they were unhappy with the wait for surgery or found the wait unacceptable (56% of URB and 44% of RUR patients). There was no significant difference between RUR and URB in patients’ acceptance of their wait for surgery (*p* = 0.09), but URB patients believed their wait for surgery made a greater contribution to health deterioration (*p* = 0.003). Thirty-eight percent of RUR and 54% of URB patients believed their surgical wait contributed to “a lot” or a “moderate” amount of deterioration in their health. **Conclusions:** Waiting times for hip or knee replacement surgery have increased to the point at which over 50% of surgical patients in 2000–2001 in RUR and URB orthopedic practices had waited longer than 9 months for surgery. In comparing these practices, there was a significantly longer wait in urban than rural practices for the initial consultation but no significant difference in waiting times for surgery. A relatively high prevalence of degenerative arthritis of the hip and knee, combined with the success of surgical procedures, has resulted in a high demand for total hip and total knee arthroplasties (THA and TKA), which has been manifested through increasing waiting times for these procedures, especially in Ontario. Studies have shown mean waiting times for an initial orthopedic consultation of 5.4 weeks1 and 8.52 weeks for THA, and 13.5 weeks1 and 15.6 weeks2 for TKA. More recent data showed mean waiting times in Ontario of 17 weeks for THA and 22 weeks for TKA.3 Reported mean waiting times in London, Ont., for THA were 6.5 months based on data collected between 1993 and 1998.4 Data from other provinces have shown mean waiting times for THA and TKA in the Edmonton, Alta., of 3.8 months, based on data from 1995 to 1997,5 and 8.7 months for THA and TKA in Saskatchewan in 1996.6 The Fraser Institute reported that in 2000–2001 the median wait in Canada was 11.4 weeks for an initial orthopedic consultation and 16.0 weeks for major joint arthroplasty.7 There has been conflicting research regarding the resulting effects of these waiting times on patients. Mahon and colleagues4 found that health-related quality of life and mobility decreased in patients waiting longer than 6 months for THA. Kelly and associates8 showed that overall pain and functional disability did not worsen while patients were waiting for their arthroplasty procedures, but they noted that the patients were already in a great deal of pain and dysfunction when they were put on the waiting list. A study that assessed patients at the preoperative clinic, retrospectively determined that they had not deteriorated physically or mentally from the time they were put on the waiting list.9 (It should be noted that the mean waiting times in these studies were 4.5 months7 [median 6.0 months8], so they were perhaps of insufficient length to show health deterioration.) There has been some indication of differences between rural (RUR) and urban (URB) patients awaiting arthroplasty. Visuri and Honkanen10 found that RUR patients waiting for THA preoperatively had poorer walking ability, poorer functional status (based on the activities of daily living) and greater disability than URB patients. In Ontario between 1985 and 1990, it was determined that waiting times differed between teaching hospitals and nonteaching hospitals: the mean wait for TKA in teaching hospitals was 16.3 weeks compared with 10.4 weeks in nonteaching hospitals.1 Thus, it is possible that patient perspectives of waiting times for arthroplasty may also be different. ## Methods We mailed surveys to all patients who underwent primary total hip or knee replacement between June 1, 2000, and June 1, 2001, in an RUR orthopedic practice (Stratford, Ont.) and an URB orthopedic practice (London, Ont.). The 2 practices are about 60 km apart. Information collected included patients’ perceived length of wait for initial consultation and for arthroplasty, ranking of the degree of acceptability of their waiting time for surgery, ranking of the effect of waiting time on their health and what would be an acceptable waiting time (Box 1). Chart reviews were conducted for all patients who returned the surveys to determine actual waiting times for initial consultation (from date of referral to date of consultation) and for joint replacement surgery (from date of surgery recommendation or put on a waiting list to the date of surgery). Patients were excluded if they did not return the survey, the required survey was incomplete or the required chart information could not be accurately determined. In addition, information regarding consultation waiting times was excluded for patients whose consultation occurred before 1999 so we could compare consultation waiting times within the same period. Box 1 ### Survey questions for patients who underwent total hip or knee arthroplasty between June 1, 2000, and June 1, 2001 | 1. How long did you have to wait for the first appointment with this surgeon? | || | 2. How long did you have to wait for your surgery (from the time you and your surgeon decided on surgery)? | | 3. Was your surgery booking: * □ as a result of a cancellation * □ at the earliest appointment available on the waiting list * □ delayed by your choice (e.g., at a more convenient time) * □ due to an emergency appointment | | 4. Please check the most appropriate box below that describes how you felt about the length of your wait for surgery? * □ it was acceptable and I had no problems with it * □ it was acceptable given the current problems with the health care system * □ I didn’t like it but I could live with it * □ I didn’t like it and I became increasingly frustrated * □ it was unacceptable | | 5. Did the wait for your surgery contribute to a deterioration of your health? * □ no not at all * □ a small amount * □ moderately * □ a lot | | 6. What do you think would have been an acceptable time to wait for your surgery? | Statistical analysis was performed using the SPSS 9.0 for Windows software package. The majority of analysis consisted of independent sample *t* tests to assess for statistical differences between groups. Paired sample *t* tests were used for analysis of the accuracy of perceived waiting times. Analysis of acceptability of waiting times and deterioration of health in comparison to waiting times for surgery was conducted using Spearman’s rank correlation. ## Results We mailed 260 surveys, and 202 (77.7%) were returned. In the London group (URB), 115 (73%) of 157 surveys were returned; 11 were excluded. In the Stratford group (RUR), 87 (84%) of 103 surveys were returned; 9 were excluded. ### Waiting times for consultation and surgery Actual mean (and standard deviation [SD]) consultation waiting times (based on chart review) were significantly shorter (*p* < 0.001) in the RUR group (1.10 [0.53] mo) compared with the URB group (3.40 [1.34] mo). There was no significant difference (*p* = 0.10) between waiting times for arthroplasty in the RUR (8.45 [3.32] mo) group compared with the URB (9.32 [3.61] mo) group (Table 1). Fifty-three percent of patients in the RUR group and 59% of patients in the URB groupwaited longer than 9 months for surgery, and 7% in the RUR group and 24% of patients in the URB group waited longer than 12 months. View this table: [Table 1](http://canjsurg.ca/content/48/5/355/T2) Table 1 Actual waiting times in months for primary total hip arthroplasty or total knee arthroplasty (based on chart review) ### Patient perspectives of waiting times Overall, patients’ perceived waiting times were quite accurate. Patients overestimated the waiting time for consultation by approximately 3 weeks (mean [and SD] perceived wait = 3.55 [3.19] mo, actual wait = 2.64 [1.57] mo, *p* < 0.001). There were no significant differences between perceived wait and actual wait for surgery (perceived wait = 8.74 mo, actual wait = 8.93 mo, *p* = 0.40), and there were no significant differences between the RUR and URB groups. The length of wait for surgery was ranked as “acceptable” or as “acceptable given the current problems with the health care system” by 56% of patients in the RUR group and by 44% of the patients in the URB (50% combined) group (Table 2). In comparison, 18% of the RUR group and 25% of the URB group described the length of this wait as being “unacceptable” or “didn’t like it and became increasingly frustrated” (22% combined). There was no significant relationship between the actual wait for surgery and the rankings of acceptability (*r* = −0.049, *p* = 0.52) and only a weak correlation (*r* = 0.16, *p* = 0.036) associating longer perceived waiting times for surgery with less acceptance. There was also no significant difference between the 2 groups (*p* = 0.092), although a trend existed to greater acceptability of the waiting times in the RUR group compared with the URB group (Table 2). View this table: [Table 2](http://canjsurg.ca/content/48/5/355/T3) Table 2 Percentage of patients ranking each acceptability survey response based on their actual waiting time for surgery In regard to the effect on health, 38% of the RUR group and 54% of the URB group said that their wait for surgery contributed to “a lot” or a “moderate” amount to deterioration in their health (47% combined) (Table 3). There was no significant relationship between the degree of perceived health deterioration and actual (*r* = −0.077, *p* = 0.31) or perceived waiting times for surgery (*r* = 0.023, *p* = 0.75). URB patients ranked their waiting times as having a significantly greater (*p* = 0.003) contribution toward deterioration in their health than RUR patients (Table 3). View this table: [Table 3](http://canjsurg.ca/content/48/5/355/T4) Table 3 Percentage of patients ranking each health deterioration survey response based on their actual waiting time for surgery Patient perspectives on what would be an acceptable waiting time for surgery showed that there was no significant difference (*p* = 0.92) between RUR (3.55 [2.00] mo) and URB (3.59 [2.10] mo) groups. When patients were compared on the basis of waiting time for surgery, it was found that acceptable times ranged from a mean of 3.36–4.34 months for all patients who waited longer than 3 months. Reported mean acceptable waiting times for surgery were 3.36 months for patients who waited 3–6 months for surgery, 3.40 months for those waiting 6–9 months, 3.70 months for those waiting 9–12 months, and 4.34 months for those who waited longer than 12 months. ## Discussion The results from this study support other reports of the recent trend toward longer waiting times, especially for THA and TKA. The combined data for the 2 groups shows mean waiting times of 2.62 months for initial consultation and 8.93 months for surgery. Overall, 57% of patients waited longer than 9 months for surgery, and 17% waited longer than 12 months. The most recent Ontario waiting time data from ICES3 was from 1996 to 1997, when waiting times were only 17 weeks for THA and 22 weeks for TKA. Assessing the accuracy of patients’ perceived waiting times compared with the actual waiting times as determined from a chart review showed that patients overestimated their wait for the initial consultation but not for surgery. The initial consultations occurred at least 1–2 years before the survey, so patient recall was considered quite reliable. Since our data were collected by a mailed survey, we do not know whether patients answered these questions from memory or had documentation. The latter could partially explain why the perceived waits for surgery were quite accurate, while the perceived waiting times for the initial consultation were not as accurate since these dates may not have been written down or as easily remembered. The accuracy of patient reported waiting times is an important issue because some studies depend on them to measure waiting times. Hawker11 found that TKA patients could accurately recall details about perioperative care and proposed that recalled waiting times would also likely be accurate. The findings of the our study support reasonable patient recall. Patient acceptance of waiting times for arthroplasty has not been well documented. Ho and associates2 evaluated waiting time acceptance in TKA patients in Ontario between 1985 and 1990 when mean waiting times were 8.5 weeks for initial consultation and 15.6 weeks for surgery. They found acceptance levels of 93.2% for the wait for consultation and 88.1% for the wait for surgery when patients had a choice of 2 response options (acceptable or not acceptable). They noted that the duration of the wait was highly important in determining patients’ acceptability. We found much less acceptance, with 50% of patients being dissatisfied with the waiting period. This suggests that with the increasing waiting times for THA and TKA, patient acceptance is decreasing, and that earlier data from periods of shorter waiting times may no longer be applicable. Additionally, we assessed patient perspectives of their waiting times in relation to the effect on health. We found that overall 47% of patients ranked their wait as contributing “a lot” or “moderately” to deterioration in their health. Since objective functional measures were not performed as part of this study, it is impossible to declare if health deterioration is actually occurring. However, previous research has examined this question. Mahon and colleagues4 found that patients waiting longer than 6 months for THA showed decreases in health-related quality of life and mobility while waiting for surgery. Two other studies7,8 found that patients’ health did not deteriorate while waiting for arthroplasty, but these studies had a mean wait of 4.5 months7 and a median wait of 6.0 months8 for surgery. Therefore, it is possible that neither of these studies had waiting times long enough to show a significant deterioration in health that might have presented itself. There were several significant differences between the RUR and URB groups. The wait for initial consultation was significantly shorter for the RUR group than the URB group (1.10 v. 3.40 mo), but there were no significant differences with respect to waiting times for surgery (8.45 v. 9.32 mo). Patients in the URB group ranked their waiting times as having a significantly greater contribution to deterioration in their health than those in the RUR group, but there was no significant difference in acceptability. Many factors must be taken into account before drawing conclusions from this study, particularly in comparing RUR and URB groups. It should be remembered that only 2 orthopedic practices were analyzed and that these practices are in close proximity (60 km apart). To assess whether significant numbers of patients were travelling between the 2 areas (i.e., RUR to URB or URB to RUR), a post-hoc postal code analysis was conducted. The results showed 43.9% of the URB group were from the London area whereas only 1.9% the RUR group were from the London area; 28.2% were from the Stratford area. The differences in the types of practices also could influence the results. The URB practice is devoted solely to hip and knee adult reconstructive surgery with primary and revision arthroplasty comprising the majority of the workload, whereas the RUR practice is a general orthopedic practice, providing a wide range of surgical services including THA and TKA. It is also likely that the URB practice sees patients that are generally in poorer condition than those in the RUR practice, since it is a larger referral centre for a greater geographic area. A limitation of this study is the variable time postoperatively when patients filled out the survey. Since the survey was mailed to all patients at the same time, the actual elapsed time since surgery varied from approximately 1 to 13 months. Patient recall could be variably affected and thus affect the results that depend upon recall. Additionally, patient perceptions of their waiting times could change the further they are from their surgery date. As far as we know, both orthopedic practices would be affected by this bias, since the surgery dates ranged fairly consistently throughout the year. To eliminate this possible bias, an alternative study design could have patients complete the survey either at the same postoperative time or just before operation. Taking the limitations into account, this study suggests that waiting times for THA and TKA are increasing, and that with these longer waiting times, patient acceptance levels are decreasing and a substantial number of patients are perceiving a deterioration in their health and attributing it to their waiting times for surgery. ## Acknowledgements This study was supported in part by funding from Southwestern Ontario Rural and Regional Medicine (SWORRM) through its Rural Summer Studentship Program. ## Footnotes * The results of this research were presented at the World Organization of Family Doctors (WONCA) Fifth World Conference on Rural Health, Melbourne, Australia, Apr. 30–May 3, 2002. * **Competing interests:** None declared. * Accepted August 13, 2004. ## References 1. Coyte PC, Wright JG, Hawker GA, Bombardier C, Dittus RS, Paul JE, et al. Waiting time for knee-replacement in the United States and Ontario. N Engl J Med 1994;331:1068–71. [CrossRef](http://canjsurg.ca/lookup/external-ref?access_num=10.1056/NEJM199410203311607&link_type=DOI) [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=8090168&link_type=MED&atom=%2Fcjs%2F48%2F5%2F355.atom) [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=A1994PL56000007&link_type=ISI) 2. Ho E, Coyte PC, Bombardier C, Hawker G, Wright JG. Ontario patients’ acceptance of waiting times for knee replacements. J Rheumatol 1994;21:2101–5. [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=7869317&link_type=MED&atom=%2Fcjs%2F48%2F5%2F355.atom) [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=A1994PR23500023&link_type=ISI) 3. 1. Williams JI, 2. Badley EM Axcell T, DeBoer D, Kreder H, Williams JI. Times in the surgeon’s queue for elective primary total hip and total knee replacements. In: Williams JI, Badley EM, editors. Patterns of health care in Ontario: Arthritis and related conditions. Toronto: Institute for Clinical Evaluative Sciences; 1998. p. 133–40. 4. Mahon JL, Bourne RB, Rorabeck CH, Feeny DH, Stitt L, Webster-Bogaert S. Health-related quality of life and mobility of patients awaiting elective total hip arthroplasty: a prospective study. CMAJ 2002;167:1115–21. [Abstract/FREE Full Text](http://canjsurg.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTY3LzEwLzExMTUiO3M6NDoiYXRvbSI7czoxODoiL2Nqcy80OC81LzM1NS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 5. Kelly KD, Voaklander D, Kramer G, Johnston DW, Redfern L, Suarez-Almazor ME. The impact of health status on waiting time for major joint arthroplasty. J Arthroplasty 2000;15:877–83. [CrossRef](http://canjsurg.ca/lookup/external-ref?access_num=10.1054/arth.2000.9061&link_type=DOI) [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=11061448&link_type=MED&atom=%2Fcjs%2F48%2F5%2F355.atom) [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=000090055200009&link_type=ISI) 6. Peloso PM, Cassidy JD, Carroll L. What about the patient? Determinants of waiting times for hip and knee joint replacement surgery. Arthritis Rheum 1998;41: S588. 7. Walker M, Wilson G. Waiting your turn. 11th ed. The Fraser Institute. Sept 2001. 8. Kelly KD, Voaklander DC, Johnston DW, Newman SC, Suarez-Almazor ME. Change in pain and function while waiting for major joint arthroplasty. J Arthroplasty 2001;16:351–9. [CrossRef](http://canjsurg.ca/lookup/external-ref?access_num=10.1054/arth.2001.21455&link_type=DOI) [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=11307134&link_type=MED&atom=%2Fcjs%2F48%2F5%2F355.atom) [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=000168113500013&link_type=ISI) 9. Brownlow HC, Benjamin S, Andrew JG, Kay P. Disability and mental health of patients waiting for total hip replacement. Ann R Coll Surg Engl 2001;83: 128–33. [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=11320923&link_type=MED&atom=%2Fcjs%2F48%2F5%2F355.atom) 10. Visuri T, Honkanen R. The role of socio-economic status and place of residence in total hip replacement. Scand J Soc Med 1982;10:95–9. [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=7156919&link_type=MED&atom=%2Fcjs%2F48%2F5%2F355.atom) 11. Hawker GA. The reliability and validity of using patient survey and hospital discharge files to assess peri-operative health status and outcomes in knee replacement surgery. Toronto: Graduate Department of Community Health, University of Toronto; 1993. p. 69–94.