A single-entry model and wait time for hip and knee replacement in eastern health region of Newfoundland and Labrador 2011–2019

Canada’s publicly funded healthcare system ensures that all eligible residents in provinces and territories have access to medically necessary hospital and physician services without financial barriers. However, Canada has the longest wait times for specialists and non-emergency surgeries compared to other OECD countries (Organization for Economic Cooperation and Development) [1]. Over a half of patients had to wait over 9 months for their hip and knee replacement (HKR) surgeries [2‐15].

Long wait times for HKR surgery might be associated with an increase in medical and non-medical costs and a deterioration in health-related quality of life. A total cost of medications for patients with long wait times is higher than those with short wait times [16, 17]. Approximately 20% of patients in the workforce waiting for a hip replacement surgery have to be off of work because of negative health consequences [16]. Patients with longer wait times for HKR have difficulties with mobility, pain while waiting for their surgery [16, 18, 19].

During the past few decades, the Canadian government has made considerable effort to improve wait times for HKR. The Health Ministers announced evidence-based national benchmark of 182 days for HKR surgery [20, 21]. The National Standards Committee of the Canadian Orthopedic Association (COA) also recommended benchmarks for maximum acceptable wait time (MAWT), including two intervals: an MAWT benchmark within 90 days for consultation, and an MAWT benchmark within 182 days for surgery [22]. Most provinces have developed strategies to strive to meet the benchmarks. A central intake system, known as a single-entry model (SEM), is an innovation for managing wait times [23]. Under traditional models, surgeons receive referrals and manage their own waiting list. When a patient is referred to a surgeon whose appointment slots are all unavailable, the patient has to wait until a vacancy is available, even if another surgeon is available [24]. In contrast, in the SEM, multiple queues are consolidated into a single queue through a central intake system, and patients can meet the next available orthopedic surgeon based on their urgent conditions [25‐27]. Many studies show that the SEM improved wait time for consultation (WT1) [28‐31], wait time for surgery (WT2) [27‐32], and a total wait time (TW) for HKR through the SEM [27, 29]. Wait time for consultation (WT1) is the duration from the date when the surgeon’s office, or central intake receives the referral [33‐37], or when the referral is made by family doctor [38, 39] to the date when a patient has consultation with surgeon [33‐39]. Wait time for surgery is defined as a wait time period from the date when a surgeon and a patient decide to surgery [33‐38], or when a booking form is received by the health authority [39] to the date when a patient receives surgery [33‐39].

The Eastern Health region of Newfoundland and Labrador implemented an Orthopedic Central Intake (OCI) clinic and developed a routine priority classification to triage patients to a surgeon for consultation based on the patient’s urgency level since 2011. An interdisciplinary assessment team in the OCI clinic, including a nurse, social worker, physiotherapist, occupational therapist and appointment clerk, assessed the urgency for surgery considering stage pathology or complex MSK issue, level of dysfunction, and whether conservative treatment opinions failed based on the information on the referral form from the primary physicians and the results of X-ray if possible as well as other information collected during the team’s interaction with patients after a referral was made. Then the team assigned patients with highest priority routine referral as Priority 1 (end stage pathology or complex MSK issue, high level of dysfunction, and conservative treatment opinions failed); those with moderate priority routine referral as priority 2 (moderate to end stage pathology or complex MSK issue, moderate to high functional impairment despite best conservative); those with low priority routine referral as priority 3 (early to moderate stage pathology, moderate functional impairment, minimal evidence of conservative management trialed or currently managing with conservative interventions); and priority 4 for not appropriate for orthopedic surgical consultation (early-stage disease, minimal symptoms/functional impairment, minimal evidence of conservative intervention trialed and/or patient responding to conservative treatment). According to the priority classification, patients with priority 1, 2, and 3 would be booked for an appointment with a surgeon within 45 days, 90 days, and 6 months to under 12 months of receipt of the complete referral, respectively. Patients with priority 4 would not be considered suitable for consultation at triage assessment, but they could be booked an appointment for consultation if they do not respond to their non-surgery treatment [40]. Based on the annual reports of Eastern Health (2011–2014) [41‐43], the median WT1 decreased from 95 days to 47 days for priority 1 and 2, and from 182 days to 123 days for priority 3 and 4.

There are challenges in using priority tools for managing wait times. First, patients with low priority might never reach the top of the waiting list when surgeons see a high volume of patients with high priority [44]. Cipriano et al. [45] demonstrated that after 5 year of implementing strict clinical prioritization, the number of patients receiving surgery within MAWT increased in patients with higher urgent scores, but decreased in patients with lower urgent scores. However, the OCI clinic at Eastern Health has not tracked WT2 by priority and, as a result, little is known about whether patients assigned a higher priority level receive surgeries sooner than those with a lower priority level. Second, most studies used descriptive analyses to examine WT1 [28‐31], WT2 [29‐31, 46], and TW [27, 29]. Consequently, influential factors have not been controlled in these studies [28‐32, 46]. One study used a linear regression model to estimate WT2 controlling explanatory variables, but not WT1 and TW [27]. This study addressed these gaps in literature by using a survival analysis to examine whether and to what extent the priority classification in the single-entry model reduced wait times for hip and knee replacements while adjusting for covariates of age, diagnosis type, patient’s preference, initial referral form status, and year of referral.

A number of health regions in Canada shortened the WT1 after implementing a SEM [28‐31, 51]. Our findings revealed that WT1 in patients with HKR was improved through the SEM at Eastern Health. A median WT1 pre-implementing OCI clinic was 168 days in 2006 to 210 days in 2010 [3‐7]. After implementing the OCI clinic, a median WT1 was 49 days in priority 1, 75 days in priority 2, and 194.5 days in priority 3 for hip replacement surgery, and 54 days in priority 1, 82 days in priority 2, and 202 days in priority 3 for knee replacement surgery.

Studies have shown that incomplete initial referral form increased WT1 [52, 53]. Our study revealed that incomplete initial referral form was more likely to prolong WT1 than completed referral form. Choosing to see the next available surgeon for consultation may shorten WT1 [52, 54‐56]. However, many patients are unlikely to consider switching surgeons [55]. Marshall et al. [54] found that patients were willing to wait a long time to meet an excellent reputation before accepting the next available surgeon. This study showed that most patients were willing to choose the next available surgeon and that choosing the next available surgeon reduced WT1. The relationship between age group and the likelihood of receiving a consultation booked early became nonsignificant while controlling independent variables. This is because those variables were probably positive confounders of the relationship between age group and WT1. Similarly, the effect of diagnosis on the probability of getting a consultation were nonsignificant when controlling possibly positive confounders.

Some previous studies have showed that WT2 was improved through the SEM [27‐29, 31]. However, estimated Eastern Health median WT2 in this study were much higher than those in Canadian Institute for Health Information (CIHI) report that were from 97 days in 2014 to 149 days in 2019 for hip replacement, and from 108 days in 2014 to 157 days in 2019 for knee replacement [57]. This could because the median wait times from patients whose consultations or surgeries were delayed due to personal reasons were not included when determining the median wait times in the provincial wait times system [58]. The improvement of WT2 also depends on some factors such as the availability of non-physician operation room personnel or the availability of inpatient hospital beds for surgical patients may result in delaying elective surgeries [59, 60]. There was a nonsignificant difference in possibility of having a surgery between patients with priority 1 and those with priority 3 after controlling factors for HKR. This might be because urgent clinical ratings for HKR depend on clinical conditions such as pain, stiffness, function, and others decided by orthopedic surgeons [61, 62], which further studies need to investigate.

The main clinical indication for a total joint arthroplasty is osteoarthritis that accounted for over 90% of procedures for hip and knee [63]. The majority of HKR participants in the study were diagnosed with osteoarthritis. The study found that patients with hip osteoarthritis had to wait a longer time for their hip replacement surgery than those with other arthritis disorders such as rheumatoid arthritis. In contrast with rheumatoid arthritis that is best managed by a rheumatologist [63, 64], osteoarthritis is a progressive disease, and most patient with osteoarthritis will self-manage their disease such as changing their lifestyle, using over-the-counter analgesics, or looking for treatment by primary healthcare professional (e.g., physiotherapist, family doctors) before being referred to orthopedic surgeon for consultation. Of those requiring arthroplasty surgery, they will prepare themselves medically, socially, and functionally, as well as maintain their comorbidities under control before surgery [63]. These could result in wait longer times for surgery in patients with osteoarthritis than those with other arthritis disorders.

The study also revealed that choosing the next available surgeon for consultation did not improve WT2. This was a warning when surgeons were overburdened with large number of patients requiring surgery. Expanding the pool of participating surgeons for consultation is necessary to prevent the balance of waiting time across surgeon when the number of referrals choosing the next available surgeon increases. Developing a pool of surgeons for surgery should be also considered. The SEM in Eastern Health gave patients the choice of the next available surgeon for consultation, but surgeons still manage their own waiting list for surgery. In other words, when patients meet a surgeon for consultation, they have to wait for surgery performed by that surgeon, even if another surgeon is available. However, little is known if offering a choice of the next available for surgery can improve wait time for surgery, which need further studies.

An improvement of TW for HKR surgery through a SEM in Winnipeg Central Intake Service (WCIS) [27]. In contrast, the SEM at Eastern Health have not improved TW for HKR. The reports from the Fraser Institute [3‐7] demonstrated that the median TW for orthopedic surgery in Newfoundland ranged from 257.6 days in 2006 to 436.8 days in 2010. Our findings were higher than values of the Fraser Institute’s reports. However, the use of values from the Fraser Institute’s reports should be used with cautions because the reports were based on surveys with small sample sizes from 14 to 19 questionnaires mailed out to the province [3‐7]. Age group might impact patients willing for surgery. The risk of revision in patients under 65 is higher than in those at 65 or older [65‐67], so this might make young patients are likely more unwilling to consider hip or knee replacement surgery than their counterparts [66‐70]. After controlling factors, diagnosis was an individual factor influencing the probability of having a hip replacement surgery since patients were referred to by their physician, while the effect of diagnosis on the likelihood of getting a knee replacement surgery was nonsignificant. Therefore, the multiple Cox hazard regression model allows us to evaluate the effect of diagnosis on wait times for hip and knee replacement while simultaneously controlling negative confounding effects or positive confounding effects that reduce to underestimate or overestimate results, respectively.

The study provided an insight into the improvement in wait time for consultation while using the priority classification in the single-entry model in Easter Health region of Newfoundland and Labrador. Hip and knee replacement patients with high priority were found to have consultation booked sooner than those with low priority, whereas the association between priority levels and wait time for surgery after decision for surgery was made has not well-established. Potential factors including initial referral form status and patient’s preference for a specific surgeon may delay consultation or influence patient’s willingness to have surgery through the SEM. Overall, it was found that the implementation of the single-entry model helped reduce total wait time and patient preference indicated at referral was not related to total wait time for surgery. Although age was not significantly related to wait time for consultation and for surgery after decision for surgery was make, patients under age 65 was found to wait longer for surgery after the referral made by a primary care physician than those aged 65 or above. Given the study’s findings and limitations, further studies could provide more insights about relevant factors that matter and significantly impact wait times.