Access to elective and acute orthopaedic surgery in Dunedin: an analysis of surgical delay

Background: Delay in surgical intervention may lead to significant personal, medical and economical consequences. For individuals undergoing treatment in the public health system, there is inevitably a delay in access to surgery. Access to elective joint replacement surgery can take anywhere from three months, to more than a year. Acute orthopaedic procedures may also be delayed due to clinical and logistical reasons. Thus the aim of this study was to compare outcomes of patients undergoing total hip and knee replacement surgery in the public and private health sectors. In addition to this, the contributing factors to acute surgical delay, and the cost of any surgical delay in Dunedin Hospital has also been investigated along with patients’ perspective of the time spent waiting for surgery. Methods: For the elective arm of the study, 232 public and 231 private patients were retrospectively recruited using New Zealand Joint Registry data. This included 253 that had total hip joint arthroplasty and 210 that had total knee joint arthroplasty. Six-month Oxford Hip and Knee Scores were the primary measure used to compare outcomes between the two groups where the 0-48 scoring system is used. NHI numbers were also used to gain access to other surgical data. For the acute arm of the study, 472 patients who underwent a total of 507 acute orthopaedic procedures were recruited retrospectively. Patients were recruited using the Dunedin Hospital surgical theatre management database and NHI numbers were used to access additional clinical information. In addition to this 47 patients were recruited prospectively to undergo a questionnaire of their perspective of waiting for surgery in Dunedin Hospital. Results: The elective arm of this study showed that private patients achieve better six month postoperative outcomes than public patients. For those undergoing THJR, private patients had a mean score of 41.74 (SD=5.7) whereas the mean for public patients was 37.94 (SD=9.1). For TKJR patients, private patients had a mean six-month postoperative score of 40.82 (SD=6.0) and public patients mean was 36.55 (SD=8.1). These differences in score persisted after adjustment for age and gender. For the acute arm of this study, 66.7% of the 507 procedures reviewed were delayed. Of the cases that were delayed, 84.3% were delayed due to a logistical reason such as unavailability of theatre time. Other factors associated with surgical delay included the priority grade, day of the week surgery was booked, and the anatomical location of the trauma. The total cost of delay was found to be approximately $145,800 for all surgeries delayed due to a logistical reason. Conclusion: The difference seen between public and private groups for hip replacement surgery supports the limited amount of prior literature. This study is the first that shows a difference in postoperative outcome for knee replacement surgery between public and private patients. In addition to this, findings show that there is a large amount of surgical delay currently present in Dunedin Hospital that comes at a high cost to the healthcare system. Prior literature suggests that a dedicated orthopaedic trauma operating theatre will reduce surgical delay. Finally, patient satisfaction with their time waited for surgery is associated with the timeliness of their surgery, and the communication they receive from medical staff