A bird can't fly on one wing: patient views on waiting for hip and knee replacement surgery

Identifying and Understanding the Non-Clinical Impacts of Delayed or Cancelled Surgery in Order to Inform Prioritisation Processes: A Scoping Review

The COVID-19 pandemic has resulted in significant delays to non-urgent elective surgery. Decision making regarding prioritisation for surgery is currently informed primarily by clinical urgency. The ways in which decision making should also consider potential social and economic harm arising from surgical delay are currently unclear. This scoping review aimed to identify evidence related to (i) the nature and prevalence of social and economic harm experienced by patients associated with delayed surgery, and (ii) any patient assessment tools that could measure the extent of, or predict, such social and economic harm. A rapid scoping review was undertaken following JBI methodological guidance. The following databases were searched in October 2020: AMED; BNI; CINAHL; EMBASE; EMCARE; HMIC; Medline; PsychINFO, Cochrane, and the JBI. A total of 21 publications were included. The findings were categorised into five themes: (i) employment, (ii) social function and leisure, (iii) finances, (iv) patients' experiences of waiting, and (v) assessment tools that could inform decision making. The findings suggest that, for some patients, waiting for surgery can include significant social, economic, and emotional hardship. Few validated assessment tools exist. There is an urgent need for more research on patients' experiences of surgical delay in order to inform a more holistic process of prioritising people on surgical waiting lists in the COVID-19 pandemic recovery stages.

It's not you, it's me: A descriptive study of patient complaints and surgeon understanding

BACKGROUND

Patient complaints are an underutilized and under-addressed issue in general surgery. They represent a unique sphere of interaction for surgeons and patients to understand motivations and failures in the delivery of healthcare. The aims of this study were to identify motivators of patient complaints and understand surgeon's awareness of this issue.

METHODS

A retrospective review of patient complaint data in a single regional general surgical department was undertaken between the periods October 2017 to June 2020 and June 2018 to October 2020 relating to patient demographics and subject of complaint. Secondly, an anonymous survey was conducted across the same department and results tabulated by seniority.

RESULTS

Two hundred and nineteen complaints were received during the study period. One hundred and thirteen were made by patients, while 56 were made by family members. One hundred and fifty-nine complaints were related to an inpatient episode of care, and 152 were made in writing. The majority of complainants were female, with a mean age of 52. The most common reason for complaint was "treatment" (n = 102), followed by communication (n = 48), and humaneness/caring (n = 44). Consultant surgeons and surgical trainees placed communication, humaneness/caring, and professionalism as most likely to incite complaints, while interns were more likely to prioritize other measures such as patient healthcare rights and medications.

CONCLUSION

Patient complaints remain a relatively under-utilized resource in addressing the downfalls of general surgical departments. This study reports patient demographics that are congruent with the literature and highlights that surgeons prioritize many non-technical skills in the maintenance of the doctor-patient relationship, in contrast to preconceptions.

What constitutes feeling safe at home? A qualitative interview study with frail older people receiving home care

Aim

To highlight experiences of what constitutes feeling safe at home among frail older people receiving home care.

Design

Qualitative descriptive study.

Methods

The sample consists of 12 individual recorded interviews with frail older people in their homes. Interviews were transcribed verbatim and analysed using qualitative content analysis. The data collection was performed in spring 2018.

Results

The analysis resulted in three categories: "Having a feeling of 'at-homeness'" describes the older people's surrounding environment and their efforts to maintain independence; "being able to influence" describes the importance for older people to shape their care by being in control and having an opportunity for self-determination in the context of home care; and "being able to trust staff" relates to expecting staff's knowledge and skills and to appreciating the staff's ability to create positive relations.

Improving the quality of care with a single-entry model of referral for total joint replacement: a preimplementation/postimplementation evaluation

OBJECTIVES

We assessed: (1) waiting time variation among surgeons; (2) proportion of patients receiving surgery within benchmark and (3) influence of the Winnipeg Central Intake Service (WCIS) across five dimensions of quality: accessibility, acceptability, appropriateness, effectiveness, safety.

DESIGN

Preimplementation/postimplementation cross-sectional design comparing historical (n=2282) and prospective (n=2397) cohorts.

SETTING

Regional, provincial health authority.

PARTICIPANTS

Patients awaiting total joint replacement of the hip or knee.

INTERVENTIONS

The WCIS is a single-entry model (SEM) to improve access to total hip replacement (THR) or total knee replacement (TKR) surgery, implemented to minimise variation in total waiting time (TW) across orthopaedic surgeons and increase the proportion of surgeries within 26 weeks (benchmark). Impact of SEMs on quality of care is poorly understood.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes related to 'accessibility': waiting time variation across surgeons, waiting times (Waiting Time 2 (WT2)=decision to treat until surgery and TW=total waiting time) and surgeries within benchmark. Analysis included descriptive statistics, group comparisons and clustered regression.

RESULTS

Variability in TW among surgeons was reduced by 3.7 (hip) and 4.3 (knee) weeks. Mean waiting was reduced for TKR (WT2/TW); TKR within benchmark increased by 5.9%. Accessibility and safety were the only quality dimensions that changed (post-WCIS THR and TKR). Shorter WT2 was associated with post-WCIS (knee), worse Oxford score (hip and knee) and having medical comorbidities (hip). Meeting benchmark was associated with post-WCIS (knee), lower Body Mass Index (BMI) (hip) and worse Oxford score (hip and knee).

CONCLUSIONS

The WCIS reduced variability across surgeon waiting times, with modest reductions in overall waits for surgery. There was improvement in some, but not all, dimensions of quality.

Patient attitudes toward pooled surgical waitlists in urogynecology

INTRODUCTION AND HYPOTHESIS

Pooled surgical waitlists are used to maximize the use of surgical resources; however, patients' views of this strategy are poorly understood. We sought to evaluate patients' attitudes toward a pooled waitlist for urogynecology and pelvic reconstructive surgical procedures.

METHODS

Patient and provider focus groups were used to inform the design of a survey that was distributed to patients at the time of consent for female pelvic reconstructive surgical procedures. All responses were collected anonymously. Patient attitudes toward surgical wait times and the potential for a pooled surgical waitlist were explored. Grouped responses by age, procedure type, and perceived disease severity were examined.

RESULTS

One hundred seventy-six patients were surveyed. Thirty-four percent were amenable to the option of a pooled surgical waitlist; 86% agreed or strongly agreed that they preferred to have their surgery performed by their own care provider. Only 18% would agree to be on a pooled surgical waitlist if it shortened their wait time. Older women (≥ 65 years) were more likely to disagree or strongly disagree that they "would like the option of having surgery done by the next available skilled surgeon" (56.2% vs. 72.0%, p = 0.028). Self-perceived severe disease and mid-urethral sling surgery were not associated with a higher acceptance of pooled surgical waitlists.

CONCLUSIONS

Acceptance of pooled surgical waitlists among urogynecology patients was overall low, irrespective of disease severity. Improving our understanding of urogynecology patients' concerns and potentially negative perceptions of surgical waitlists is needed to ensure patient comfort and satisfaction are not compromised if this strategy is adopted.

Comparison Of Expectations For Health Services Between Inpatients From Mental Health Department And Endocrinology Department In China

BACKGROUND

Patient expectations for health services refer to the anticipation or the belief about what should be encountered in the healthcare system. Understanding patient expectations can improve patient satisfaction and healthcare compliance. It is particularly important for patients with mental disorders, as greater healthcare compliance is required for them due to the chronic and relapsing nature of their diseases. However, little is known about expectations among Chinese patients with mental disorders.

OBJECTIVE

To examine expectations for healthcare among patients with mental disorders and to compare them with those of patients with chronic physical diseases.

PATIENTS AND METHODS

A cross-sectional survey was conducted among two inpatient groups, consecutively recruited from the Mental Health Department (MHD) and Endocrinology Department (ED) in one tertiary general hospital in Changsha, China. Patient expectations were measured by eight translated and modified vignettes of health system responsiveness. Group differences were compared using Chi-square tests for socio-demographic and clinical characteristics and Z-test for expectation rating. Logistic regression was performed to test whether group differences of expectations remained statistically significant after controlling for socio-demographic and clinical variables.

RESULTS

Most patients from MHD rated scenarios in vignettes on communication, choice of provider, autonomy, and social support as "meeting expectations", and rated scenarios in vignettes on prompt attention, dignity, confidentiality, and quality of basic amenities as "below expectations". In comparison, patients from MHD had similar expectations with their counterparts from ED, for prompt attention, dignity, confidentiality, communication, choice of provider, and social support; however, patients from MHD had significantly lower expectations in quality of basic amenities and higher expectations in autonomy, after adjusting for socio-demographic and clinical factors.

CONCLUSION

Like their counterparts with physical diseases, patients with mental disorders also expect prompt attention, dignity, confidentiality, communication, choice of provider, and social support in their interaction with the healthcare system. Moreover, extra attention to autonomy is needed for patients with mental disorders to meet their expectations and improve patient satisfaction.

What is the influence of single-entry models on access to elective surgical procedures? A systematic review

BACKGROUND

Single-entry models (SEMs) for the management of patients awaiting elective surgical services are designed to increase access and flow through the system of care. We assessed scope of use and influence of SEMs on access (waiting times/throughput) and patient-centredness (patient/provider acceptability).

METHODS

Systematic review of articles published in 6 relevant electronic databases included studies from database inception to July 2016. Included studies needed to (1) report on the nature of the SEM; (2) specify elective service and (3) address at least 1 of 3 research questions related to (1) scope of use of SEMs; (2) influence on timeliness and access; (3) patient-centredness and acceptability. Article quality was assessed using a modified Downs and Black checklist.

RESULTS

11 studies from Canada, Australia and the UK were included with mostly weak observational design-2 simulations, 5 before-after, 2 descriptive and 2 cross-sectional studies. 9 studies showed a decrease in patient waiting times; 6 showed that more patients were meeting benchmark waiting times; and 5 demonstrated that waiting lists decreased using an SEM as compared with controls. Patient acceptability was examined in 6 studies, with high levels of satisfaction reported. Acceptability among general practitioners/surgeons was mixed, as reported in 1 study. Research varied widely in design, scope, reported outcomes and overall quality.

CONCLUSIONS

This is the first review to assess the influence of SEMs on access to elective surgery for adults. This review demonstrates a potential ability for SEMs to improve timeliness and patient-centredness of elective services; however, the small number of low-quality studies available does not support firm conclusions about the effectiveness of SEMs to improve access. Further evaluation with higher quality designs and rigour is required.

Waiting for scheduled surgery: A complex patient experience

The aim of this study was to understand experiences of wait time among patients awaiting scheduled orthopaedic or cardiac surgery. Using a qualitative approach, 32 patients completed two interviews each regarding their wait time experiences, including effects of waiting. Patient experiences of wait time varied regardless of actual wait time and included reports of restriction, uncertainty, resignation, coping and opportunity. Participants' waiting experiences indicate a complex relationship between greater symptom severity and less tolerance for wait time. We suggest healthcare resources focus on alleviating the deleterious effects of waiting for certain patients rather than reducing absolute wait times.

Use of medical tourism for hip and knee surgery in osteoarthritis: a qualitative examination of distinctive attitudinal characteristics among Canadian patients

Background

Medical tourism is the term that describes patients’ international travel with the intention of seeking medical treatment. Some medical tourists go abroad for orthopaedic surgeries, including hip and knee resurfacing and replacement. In this article we examine the findings of interviews with Canadian medical tourists who went abroad for such surgeries to determine what is distinctive about their attitudes when compared to existing qualitative research findings about patients’ decision-making in and experiences of these same procedures in their home countries.

Methods

Fourteen Canadian medical tourists participated in semi-structured phone interviews, all of whom had gone abroad for hip or knee surgery to treat osteoarthritis. Transcripts were coded and thematically analysed, which involved comparing emerging findings to those in the existing qualitative literature on hip and knee surgery.

Results

Three distinctive attitudinal characteristics among participants were identified when interview themes were compared to findings in the existing qualitative research on hip and knee surgery in osteoarthritis. These attitudinal characteristics were that the medical tourists we spoke with were: (1) comfortable health-related decision-makers; (2) unwavering in their views about procedure necessity and urgency; and (3) firm in their desires to maintain active lives.

Conclusions

Compared to other patients reported on in the existing qualitative hip and knee surgery literature, medical tourists are less likely to question their need for surgery and are particularly active in their pursuit of surgical intervention. They are also comfortable with taking control of health-related decisions. Future research is needed to identify motivators behind patients’ pursuit of care abroad, determine if the attitudinal characteristics identified here hold true for other patient groups, and ascertain the impact of these attitudinal characteristics on surgical outcomes. Arthritis care providers can use the attitudinal characteristics identified here to better advise osteoarthritis patients who are considering seeking care abroad.

Determinants of demand for total hip and knee arthroplasty: a systematic literature review

BACKGROUND

Documented age, gender, race and socio-economic disparities in total joint arthroplasty (TJA), suggest that those who need the surgery may not receive it, and present a challenge to explain the causes of unmet need. It is not clear whether doctors limit treatment opportunities to patients, nor is it known the effect that patient beliefs and expectations about the operation, including their paid work status and retirement plans, have on the decision to undergo TJA. Identifying socio-economic and other determinants of demand would inform the design of effective and efficient health policy. This review was conducted to identify the factors that lead patients in need to undergo TJA.

METHODS

An electronic search of the Embase and Medline (Ovid) bibliographic databases conducted in September 2011 identified studies in the English language that reported on factors driving patients in need of hip or knee replacement to undergo surgery. The review included reports of elective surgery rates in eligible patients or, controlling for disease severity, in general subjects, and stated clinical experts' and patients' opinions on suitability for or willingness to undergo TJA. Quantitative and qualitative studies were reviewed, but quantitative studies involving fewer than 20 subjects were excluded. The quality of individual studies was assessed on the basis of study design (i.e., prospective versus retrospective), reporting of attrition, adjustment for and report of confounding effects, and reported measures of need (self-reported versus doctor-assessed). Reported estimates of effect on the probability of surgery from analyses adjusting for confounders were summarised in narrative form and synthesised in odds ratio (OR) forest plots for individual determinants.

RESULTS

The review included 26 quantitative studies-23 on individuals' decisions or views on having the operation and three about health professionals' opinions-and 10 qualitative studies. Ethnic and racial disparities in TJA use are associated with socio-economic access factors and expectations about the process and outcomes of surgery. In the United States, health insurance coverage affects demand, including that from the Medicare population, for whom having supplemental Medicaid coverage increases the likelihood of undergoing TJA. Patients with post-secondary education are more likely to demand hip or knee surgery than those without it (range of OR 0.87-2.38). Women are as willing to undergo surgery as men, but they are less likely to be offered surgery by specialists than men with the same need. There is considerable variation in patient demand with age, with distinct patterns for hip and knee. Paid employment appears to increase the chances of undergoing surgery, but no study was found that investigated the relationship between retirement plans and demand for TJA. There is evidence of substantial geographical variation in access to joint replacement within the territory covered by a public national health system, which is unlikely to be explained by differences in preference or unmeasured need alone. The literature tends to focus on associations, rather than testing of causal relationships, and is insufficient to assess the relative importance of determinants.

CONCLUSIONS

Patients' use of hip and knee replacement is a function of their socio-economic circumstances, which reinforce disparities by gender and race originating in the doctor-patient interaction. Willingness to undergo surgery declines steeply after the age of retirement, at the time some eligible patients may lower their expectations of health status achievement. There is some evidence that paid employment independently increases the likelihood of operation. The relative contribution of variations in surgical decision making to differential access across regions within countries deserves further research that controls for clinical need and patient lifestyle preferences, including retirement decisions. Evidence on this question will become increasingly relevant for service planning and policy design in societies with ageing populations.

"I didn't even know what I was looking for": A qualitative study of the decision-making processes of Canadian medical tourists

Background

Medical tourism describes the private purchase and arrangement of medical care by patients across international borders. Increasing numbers of medical facilities in countries around the world are marketing their services to a receptive audience of international patients, a phenomenon that has largely been made possible by the growth of the Internet. The growth of the medical tourism industry has raised numerous concerns around patient safety and global health equity. In spite of these concerns, there is a lack of empirical research amongst medical tourism stakeholders. One such gap is a lack of engagement with medical tourists themselves, where there is currently little known about how medical tourists decide to access care abroad. We address this gap through examining aspects of Canadian medical tourists’ decision-making processes.

Methods

Semi-structured phone interviews were administered to 32 Canadians who had gone abroad as medical tourists. Interviews touched on motivations, assessment of risks, information seeking processes, and experiences at home and abroad. A thematic analysis of the interview transcripts followed.

Results

Three overarching themes emerged from the interviews: (1) information sources consulted; (2) motivations, considerations, and timing; and (3) personal and professional supports drawn upon. Patient testimonials and word of mouth connections amongst former medical tourists were accessed and relied upon more readily than the advice of family physicians. Neutral, third-party information sources were limited, which resulted in participants also relying on medical tourism facilitators and industry websites.

Conclusions

While Canadian medical tourists are often thought to be motivated by wait times for surgery, cost and availability of procedures were common primary and secondary motivations for participants, demonstrating that motivations are layered and dynamic. The findings of this analysis offer a number of important factors that should be considered in the development of informational interventions targeting medical tourists. It is likely that trends observed amongst Canadian medical tourists apply to those from other nations due to the key role the transnational medium of the Internet plays in facilitating patients’ private international medical travel.

What do we know about Canadian involvement in medical tourism?: a scoping review

BACKGROUND

Medical tourism, the intentional pursuit of elective medical treatments in foreign countries, is a rapidly growing global industry. Canadians are among those crossing international borders to seek out privately purchased medical care. Given Canada's universally accessible, single-payer domestic health care system, important implications emerge from Canadians' private engagement in medical tourism.

METHODS

A scoping review was conducted of the popular, academic, and business literature to synthesize what is currently known about Canadian involvement in medical tourism. Of the 348 sources that were reviewed either partly or in full, 113 were ultimately included in the review.

RESULTS

The review demonstrates that there is an extreme paucity of academic, empirical literature examining medical tourism in general or the Canadian context more specifically. Canadians are engaged with the medical tourism industry not just as patients but also as investors and business people. There have been a limited number of instances of Canadians having their medical tourism expenses reimbursed by the public medicare system. Wait times are by far the most heavily cited driver of Canadians' involvement in medical tourism. However, despite its treatment as fact, there is no empirical research to support or contradict this point.

DISCUSSION

Although medical tourism is often discussed in the Canadian context, a paucity of data on this practice complicates our understanding of its scope and impact.

Factors and consequences of waiting times for total hip arthroplasty

BACKGROUND

Various priority criteria for waiting lists for THA have been proposed. These criteria, however, are not typically included in clinical practice, resulting in unclear management procedures. Further, the clinical effects of waiting times on subsequent pain control or function are unclear.

QUESTIONS/PURPOSES

Therefore, we asked (1) what factors affect the waiting time for THA when no prioritization criteria are implemented, and (2) does waiting time influence pain and function after THA?

PATIENT AND METHODS

We prospectively identified all 1495 patients on a waiting list for THA during a year. Of these patients, 991 fulfilled the inclusion criteria, and waiting times were available for 695, of whom 527 (76%) responded to a followup questionnaire. Variables included wait time, sociodemographic data, comorbidities, and WOMAC and SF-36 questionnaires, collected preoperatively and 6 months after surgery.

RESULTS

The mean wait time was 5 months (SD, 3.0). Patients with lower levels of pain and better function on the WOMAC scale, or better physical function on the SF-36, had longer waiting times. The gains in function were smaller for patients who waited more than 6 months. The likelihood of perceiving a gain greater than the minimal clinically important difference was greater for patients waiting less than 3 months.

CONCLUSION

Only pain and previous function were significant determinants of prioritizing patients on the waiting list. Suboptimal patient selection had clinical consequences in function gain that affect the quality of the clinical care.

Patient choice systems and waiting times for scheduled services

Access to scheduled healthcare is a continuing challenge. A synthesis of the international literature was conducted to examine the potential of patient choice systems to reduce waiting times in Canada. A multitude of factors appear to influence the actions and outcomes of patients, providers, and systems. For choice systems to be effective, there must be uptake, which requires incentives and supports. Choice should be considered as but one element of a comprehensive waiting time management strategy.

The Staffordshire arthritis, musculoskeletal, and back assessment (SAMBA) study: a prospective observational study of patient outcome following referral to a primary-secondary care musculoskeletal interface service

BACKGROUND

Recent healthcare policy has shifted the management of musculoskeletal conditions in the UK away from secondary care towards Clinical Assessment and Treatment Services at the primary-secondary care interface. However, little is known about the outcome of patients with musculoskeletal conditions referred from primary care to Clinical Assessment and Treatment Services or how best to identify those patients at high risk of poor outcome in this setting. We describe the protocol for a twelve-month prospective observational study which aims to describe the outcome of patients referred to musculoskeletal and back pain services at the primary-secondary care interface and to develop simple prognostic measures to guide clinical prioritisation and triage.

METHODS/DESIGN

All patients referred over a twelve-month period from primary care to musculoskeletal and back pain clinics in the primary-secondary care interface Clinical Assessment and Treatment Service in North Staffordshire will be mailed a postal questionnaire prior to their consultation. This will collect information on quality of life, general health, anxiety and depression, pain, healthcare utilisation including medication use, occupational characteristics, and socio-demographics. At the consultation in the interface clinic, the clinical diagnosis, investigations requested, and clinical interventions will be recorded. Follow-up data for the twelve-month period subsequent to recruitment will be collected via mailed follow-up questionnaires at 6 and 12 months, and review of medical records.

DISCUSSION

This twelve-month prospective observational study of patients referred to a musculoskeletal Clinical Assessment and Treatment Service will assess the management and outcome of musculoskeletal care at the primary-secondary care interface as proposed in the Musculoskeletal Services Framework.

Waiting for surgery from the patient perspective

The aim of this study was to perform a systematic review of the impact of waiting for elective surgery from the patient perspective, with a focus on maximum tolerance, quality of life, and the nature of the waiting experience. Searches were conducted using Medline, PubMed, CINAHL, EMBASE, and HealthSTAR. Twenty-seven original research articles were identified which included each of these three themes. The current literature suggested that first, patients tend to state longer wait times as unacceptable when they experienced severe symptoms or functional impairment. Second, the relationship between length of wait and health-related quality of life depended on the nature and severity of proposed surgical intervention at the time of booking. Third, the waiting experience was consistently described as stressful and anxiety provoking. While many patients expressed anger and frustration at communication within the system, the experience of waiting was not uniformly negative. Some patients experienced waiting as an opportunity to live full lives despite pain and disability. The relatively unexamined relationship between waiting, illness and patient experience of time represents an area for future research.

Willingness of patients to change surgeons for a shorter waiting time for joint arthroplasty

BACKGROUND

To improve access to care, many jurisdictions have proposed waiting-time benchmarks and guarantees. We assessed the willingness of patients to consider changing their surgeon to one with a shorter waiting time for arthroplasty.

METHODS

We mailed a questionnaire to 2 random samples of patients who either were awaiting hip or knee replacement arthroplasty or had had one of these procedures within the preceding 3-12 months. We used logistic regression to assess the determinants of patients' likelihood to consider changing surgeons.

RESULTS

Of 1200 responses from a sample of 2000, 557 (46%) were from patients awaiting surgery and 643 (54%) were from people who had undergone surgery. The mean age of respondents was 69.9 years (standard deviation 10.8), and 682 (57%) were women. The median waiting time for surgery was 8 months. Overall, 753 (63%) of the patients were unlikely to consider changing surgeons. Increased likelihood of changing surgeons was associated with male sex (adjusted odds ratio [OR] 1.49, 95% confidence interval [CI] 1.10-2.02), a high school education or higher (OR 1.73, 95% CI 1.15-2.62) and having already undergone surgery (OR 1.71, 95% CI 1.19-2.46). Decreased likelihood was associated with preference for a particular surgeon before referral (OR 0.57, 95% CI 0.42-0.79), a better score on the EuroQol (EQ-5D) index (a measure of health-related quality of life) (OR 0.39, 95% CI 0.24-0.66), perception that the waiting time to see the surgeon was acceptable (OR 0.50, 95% CI 0.36-0.70), perception that the waiting time to surgery was acceptable (OR 0.62, 95% CI 0.43-0.91) and perceived fairness of treatment (OR 0.53, 95% CI 0.36-0.78).

INTERPRETATION

Despite long waits for surgery, most patients, if given the choice, would be unlikely to change their surgeon to one with a shorter waiting time.

Patient and surgeon views on maximum acceptable waiting times for joint replacement

OBJECTIVE

To assess patient and surgeon views on maximum acceptable waiting times (MAWT) for hip and knee replacement, their determinants and their relationship to levels of urgency based on the Western Canada Waiting List Priority Criteria Score (PCS).

METHODS

At the decision date for surgery, orthopaedic surgeons assessed consecutive patients with the PCS and MAWT. Patients were surveyed 3-12 months post-surgery for MAWT and potential determinants.

RESULTS

The patient sample of 208 was 56% female, mean age 69 years (SD 11). Mean MAWT for patients was 18 weeks (SD 11) and for surgeons, 17 weeks (SD 11). Median MAWT for three levels of urgency (PCS) ranged from 13-17 weeks (patients) and 9-26 weeks (surgeons). Patient MAWT was unrelated to the surgeon-rated measures: MAWT (r=.05) and the PCS (r=-.10). Multiple regression analysis showed that males, knee vs. hip replacement, a longer waiting time and a perception of fairness in regard to waiting time were significant predictors of longer patient MAWT. Knee replacement, a better ability to walk without significant pain and less potential for progression of the disease were significant predictors of longer surgeon MAWT.

CONCLUSIONS

Patient and surgeon perspectives on MAWT are important to the development of waiting time benchmarks. Benchmarks based on levels of urgency ensure a more transparent and fair process for waiting time management. Knowledge of determinants of MAWT should inform better management of waiting time and access, by understanding the basis of patient and physician views on acceptable waiting times.