The journey to total hip or knee replacement
Authors: Walters Julie Lynette , Mackintosh Shylie , Sheppard Lorraine 
Published: May 2012

Objectives.
Despite the incidence of joint replacements in Australia, there is a paucity of information regarding how patients progress from their referral to their surgery. The aim of this study was to describe a patient pathway from referral to receipt of total hip replacement (THR) or total knee replacement (TKR) surgery in South Australian public hospitals.

Methods.
Patient perspectives of the pathway to THR and TKR surgery were obtained via a postal survey (n = 450) and hospital employee perspectives were attained via semi-structured interviews (n = 19). Survey data were analysed using descriptive statistics and interview data were analysed thematically.

Results.
A typical patient pathway to THR and TKR surgery can be divided into two distinct phases; referral-to-initial appointment (9–24 months), and initial appointment-to-surgery (12–15 months). This gives an overall waiting period between 2 and 3 years for THR or TKR surgery.

Conclusions.
Waiting times for THR and TKR surgery reported in this study were longer than other reports in the literature. Current Australian health policy does not consider the first (and longest) phase of the patient pathway. Excluding this initial phase could be generating an erroneous perception of the patient pathway to THR or TKR surgery, possibly leading to poorly considered health reforms.

What is known about the topic?
Meeting the demand for elective surgery services in public hospitals is an ongoing challenge for governments and health systems alike. The persistent mismatch between supply and demand has resulted in the development of waiting lists for elective total hip replacement (THR) and total knee (TKR) replacement surgery in Australia. Current state-level health policies such as the Policy Framework and Associated Procedural Guidelines for Elective Surgery Services in South Australia or the Elective Surgery Access Policy in Victoria, outline a generic pathway consisting of a few linear steps that occur immediately before receipt of surgery, without consideration of the early stages of the journey. Aside from these types of policies, we were unable to identify any published literature outlining the patient journey from referral to receipt of THR or TKR surgery. As such, our understanding of the issue is inadequate due the paucity of existing research evidence.

What does this paper add?
Our current understanding of the patient journey to THR and TKR surgery is limited to the perspective of the policy-makers, whose focus is the organisation of waiting lists and the systematic progression of an individual through the elective surgery system. This perspective reinforces the assumption that it is a simple, linear process and may lead to erroneous judgements regarding the impact that the patient pathway has on an individual and the time it takes to progress along that pathway. This study presents the patient pathway from the perspective of individuals working within the systems responsible for delivering THR and TKR surgery and from patients who have received a joint replacement in a South Australian public hospital. As such, this paper provides new insight into the length, impact and features of the entire patient journey, rather than a snap-shot of the final stages.

What are the implications for practitioners?
This study is the first step towards better understanding of the patient pathway to joint replacement surgery in Australian public hospitals. Greater understanding of the complete pathway and identification of areas of congestion within the pathway, as evidenced by longer waiting periods, offers insight into areas with the potential for effective reforms. Should the patient pathway be significantly altered, the experience of practitioners responsible for the interim and postoperative management of patients undergoing THR and TKR surgery will also be changed. Additionally, practitioners currently frustrated by the long delays experienced by their patients who are in need of elective surgery in Australian public hospitals, could have that frustration abated by system improvements that reduce the length and complexity of the pathway to joint replacement surgery.