Academic journal article Australian Health Review

The Journey to Total Hip or Knee Replacement

Academic journal article Australian Health Review

The Journey to Total Hip or Knee Replacement

Article excerpt


In Australia in 2007-08, there were 7688 admissions to public hospitals for elective total hip replacement (THR) surgery and 10947 admissions for elective total knee replacement (TKR) surgery.1 Despite this, we were unable to locate any published data outlining how patients progressed from the time of their referral to a public hospital, to the time they received joint replacement surgery.

The focus of the literature reporting patient pathways has predominantly been related to strategies for reducing length of stay in hospital,2-4 minimising readmission rates,2 lowering cost,3,5 or improving postoperative outcomes,4,6,7 and most relates to disciplines other than orthopaedic surgery. Other associated studies have focussed on waiting lists and waiting time8-13 and no published literature could be identified reporting the patient pathway from referral to THR or TKR surgery with a focus on the public elective surgery system.

Current health policy in Australia includes the use of urgency categories for elective surgery procedures in public hospitals, which relate to the period between a patient's initial appointment with an orthopaedic surgeon and receipt of surgery. Categories one (urgent, admission within 30 days), two (semi-urgent, admission within 90 days), and three (non-urgent, admission within 12 months) are active categories, whereas categories four (medical deferred admission) and five (patient deferred admission) are deferred.14 The waiting time targets associated with urgency categories are quantifiable, and therefore, convenient measures of the success of a health service.15 An inability to meet targets could be viewed as evidence of the public health service failing to provide healthcare, challenging a major principle of the public health system in Australia - access to healthcare irrespective of one's ability to pay for it.16 Waiting times for public hospital services are therefore an important public policy issue in Australia.

A patient pathway represents one individual's journey to THR and TKR surgery and can be a useful representation of that person's experiences. The focus of this paper is to describe a patient pathway from referral to receipt of THR or TKR surgery in South Australian public hospitals.


Patient perspectives of the pathway to THR and TKR surgery were obtained via a postal survey and hospital employee perspectives were attained via semi-structured, face-to-face interviews lasting between 30 and 90 min.

Ethics approval was obtained from the University of South Australia Human Research Ethics Committee and the ethics committees of the four participating hospitals.

The patient survey


In April 2009, all patientswho had undergone elective primary THR or TKR surgery in 2008 in four South Australian public hospitals were identified. Patients were excluded if they had undergone revisionTHRorTKR(n = 37), uni-compartment knee replacement (n = 31) or THR or TKR due to trauma or emergency (n = 142). Individuals residing in residential care facilities or who had poor cognition were excluded (n = 16), as were those who had undergone other types of orthopaedic surgery (n = 46).

The questionnaire

A questionnaire designed to examine patients' experiences of THR and TKR surgery was mailed to all potential participants (n = 651) with instructions and a reply paid envelope. Nonresponders (identified via a participant code) were sent a reminder letter and a second copy of the questionnaire 3 weeks after the initial mail-out. The questionnaire consisted of closed-ended questions relating to respondent's characteristics, waiting time for THR or TKR surgery, the provision of preoperative information and individual's expectations and experiences of the elective surgery system. These topics were selected to generate an overall picture of the patient pathway to THR or TKR surgery within the hospitals under examination. Responses to closedended questions involved a combination of 5-point Likert scales, dichotomous yes/no answers and questions requiring respondents to rank a series of predetermined factors. …

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