Managing the demand for elective orthopaedic surgery:Challenges, strategies and results in New Zealand

Introduction. There is increasing demand for orthopaedic surgery and public health systems, in NZ and around the world, are struggling to manage. In New Zealand emphasis has been placed on fairness, timeliness, and giving the patient certainty which has led to the development of prioritisation systems and explicit rationing. This thesis of publications is based on research undertaken in Dunedin over the past 20 years. During this period there has been an increasing mismatch between demand and capacity for orthopaedic surgery in general, and hip and knee arthroplasty in particular. A variety of strategies have been employed to try to improve access to elective orthopaedic surgery. Methods The thesis is divided into chapters examining various aspects of the problem. 1) Drivers for the increasing demand for elective orthopaedic surgery, and competing demands for resource including acutes. 2) Carpal tunnel syndrome. What we can achieve with good access. 3) Prevention. Neonatal screening for developmental hip dysplasia 4) Alternatives to surgery. Improving non-operative management and comparing results with surgery. 5) Scoring, prioritisation and consequences of rationing with respect to total joint replacement (TJR). 6) Improving the perioperative management of patients. 7) Results of surgical treatment. Getting it right first time and improving the outcomes of surgery Results. There is not equity of publicly funded provision of total joint replacement (TJR) across the country. The demand for surgery in Otago has been quantified and is increasing. There is little that can be done to prevent the demand. However, screening for Developmental Dysplasia of Hip (DDH) can reduce late presenting hip dislocation and its long-term 6 sequelae. Alternative models of care have been effective in managing CTS. There is a high incidence of CTS in the elderly with good results from surgery. Non-operative management through a dedicated physiotherapy led clinic can be helpful for patients with hip and knee osteoarthritis (OA). Patients with knee OA are more likely to benefit than those with hip OA. However, the functional results at long term follow up are poorer than those who have undergone surgery. The scoring tools used to prioritise TJR have been validated but they are not discriminatory around the threshold. Declining surgery and returning patients to their General practitioner (GP) achieves little especially for patients with hip OA who are more likely to deteriorate. The long-term effects of rationing and under provision leads to worsening severity of patients qualifying for public surgery. Gains in health related quality of life are related to severity at presentation but those most severely affected may not get as good a final result. Hip and knee replacement are highly cost-effective procedures by three years. Enhanced recovery protocols have resulted in improved efficiency and shorter patient stays despite older and sicker patients. Excellent long term results have been achieved following Total Hip Replacement (THR) with up to 95% revision free survival at 18 to 20 years which match or surpass published international results. Choice of implant fixation is important with hybrid fixation in THR having the lowest risk of revision surgery. Conclusions Elective orthopaedic interventions such as carpal tunnel decompression and total joint replacement are highly effective. There is a limited role for non-operative treatment in end stage hip and knee OA. Scoring and rationing may be effective up to a point. There have been gains in efficiency despite older and sicker patients presenting for surgery. Despite these efforts, there remains a significant mismatch between demand and capacity and there is a clear need for increased investment in elective orthopaedic surgery