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- PATIENTS AND METHODS
In Australia, total knee replacement (TKR) and total hip replacement (THR) surgery are common, with the number of procedures performed increasing by ∼6% per year (1). The median waiting time for these procedures in Australian public hospitals was 137 days for TKR and 93 days for THR in 2002–2003, and 19% and 12% of patients waited longer than 1 year for TKR and THR, respectively (2). The Australian public hospital system provides free medical treatment to all permanent Australian residents under the taxpayer-funded Medicare scheme, but is associated with lengthy waiting lists for elective procedures. Large waiting lists for joint replacements are also common in many other countries, including the United Kingdom (3), Canada (4), and the Netherlands (5). The Organisation for Economic Co-operation and Development (OECD) recently reported that waiting for publicly-funded elective surgery is regarded as one of the most important problems affecting health systems in OECD countries (6). In addition, public opinion surveys have shown that waiting for specialist assessment and elective surgery are perceived as the greatest shortcomings of the health care system (7).
Waiting lists have become an increasing frustration for policy makers and health care professionals, with the expectation of growing demand in coming years due to the increasing prevalence of arthritis in aging populations (8). Increased need for joint replacement combined with limited public hospital resources means that waiting lists will continue to present a large problem for many developed countries in the years ahead. For the individual with end-stage arthritis, the period of waiting for surgery is complicated by ongoing pain and reduced physical function.
Currently, there are limited comprehensive and representative data on physical, psychosocial, and economic status of patients at entry to orthopedic waiting lists for lower-limb total joint replacement. Documentation of the status of patients on waiting lists is an important clinical issue because previous research has shown that high preoperative pain and poor physical function predict poor surgical outcomes up to 2 years following total hip or knee replacement (5, 9).
Socioeconomic status may also play a role in determining timely access to THR and TKR. Recent research from the United Kingdom showed that individuals who received means-tested welfare benefits were less likely to have knee arthritis managed by a hospital consultant and were less likely to be on a waiting list for knee replacement, compared with individuals who were not receiving benefits (10). Further research has also reported lower rates of hip and knee replacement in the United Kingdom for persons with the lowest socioeconomic background (11). A similar disparity in surgery rates also exists in the United States, with differences in health beliefs, economic, and personal resources cited as possible causes (12). If persons from lower socioeconomic groups have delayed access to orthopedic waiting lists, factors such as quality of life and physical function may be more adversely affected by waiting; this may lead to poorer outcomes from eventual surgery.
The aim of this study was to report the health-related quality of life (HRQOL), psychological distress, physical function, and self efficacy of patients waiting for lower-limb joint replacement and to examine whether these factors are associated with socioeconomic status.
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- PATIENTS AND METHODS
This study found that patients on a waiting list for TKR or THR had extremely poor HRQOL, and a large proportion (15%) considered themselves to have a health state equivalent to or worse than death. These findings demonstrate that end-stage arthritis has a pervasive impact on psychological wellbeing and social health, in addition to physical wellbeing. Although the majority of patients have poor wellbeing, women and those in lower socioeconomic groups have the poorest wellbeing, indicating inequities in the management of patients with arthritis.
Poor HRQOL and high levels of psychological distress in this patient population are probably due to a combination of reduced physical mobility and ongoing severe pain. However, participants of lower socioeconomic status had significantly poorer HRQOL and higher psychological distress. It is well established that persons living in poor communities have worse health than persons in wealthy areas (25), and our data support this. Potential contributing factors may include increased difficulty obtaining health care information, lower health literacy, or reduced access to health professional services. Studies conducted in the United States and the United Kingdom found that patients with the lowest socioeconomic status had significantly lower rates of joint replacement, but explanations for these findings have been limited (11, 26). An increased aversion to undergo surgery is unlikely to be responsible, because a Canadian study reported that patients from lower socioeconomic backgrounds were equally willing to undergo joint replacement when compared with those of higher socioeconomic status (27). In the present study, women had poorer HRQOL, self efficacy, and physical function compared with men. This may be related to sex differences surrounding functional roles, reporting of symptoms, or in accessing medical services. In support of the latter possibility, a recent United Kingdom population survey reported that women requiring TKR were less likely than men to be under the care of either a general practitioner or a hospital consultant for their knee condition (10). This is an important area for further research to identify specific social and economic determinants of health and mechanisms to facilitate sex and social health care equity.
There have been only limited reports of the HRQOL of patients waiting for joint replacement. The EuroQol utility instrument was administered to patients entering a THR waiting list in the Netherlands with similarly poor HRQOL reported, but there was greater variability within the sample (5). Psychological distress has not been previously investigated in this patient group. Studies in a variety of settings have identified a strong link between chronic pain and high psychological distress (28). The prospect of a prolonged wait for surgery (up to 3 years in many Australian public hospitals) may have also contributed to this psychological morbidity. In addition, many patients will have already endured a protracted wait for an initial appointment with an orthopedic surgeon prior to entry to the waiting list. It is likely that protracted periods of waiting lead to substantial physical, psychological, and economic decline and may also compromise outcomes from joint replacement surgery.
A potential indicator of personal resources is self efficacy, or a person's confidence in his or her ability to perform a particular behavior (29). In the context of joint replacement surgery, self efficacy relates to how confident patients are to undertake activities to reduce symptoms, and how they might cope with the wait for surgery and the recovery process after surgery. Although causal inferences from these cross-sectional data are problematic, the substantial correlation between self efficacy and these variables supports the application of programs to improve self efficacy, such as patient education and self-management courses (22, 30, 31). The level of self efficacy prior to joint replacement surgery may also have important implications for postoperative recovery and warrants further research.
This study documented physical function with the WOMAC index. This instrument is disease specific, therefore normative data are not available for comparison. However, the mean subscale scores were similar to those reported by Kelly et al (4) and Ostendorf et al (5) in their assessments of patients entering Dutch and Canadian waiting lists, respectively, for lower-limb joint replacement surgery. In contrast to the HRQOL and psychological distress findings, the WOMAC demonstrated no differences across demographic groups. This may indicate that physical function is similarly restricted for most patients with end-stage arthritis, or that this questionnaire was not sensitive enough to detect subtle differences in common daily activities.
A limitation of this study is the large number of patients excluded due to insufficient English language skills. People from non-English speaking backgrounds tend to be immigrants and are generally poorer, with reduced access to health care. Therefore, our findings may well be a substantial underestimate of the social disparities in health in the orthopedic waiting list population.
This study has comprehensively documented the psychosocial and physical status of patients entering an orthopedic waiting list. The results clearly indicate that low socioeconomic status, low self efficacy, and female sex may compound the physical and psychological effects of arthritis. Given the protracted waiting times for joint replacement surgery in Australia and other countries, strategies to improve physical and psychological wellbeing while patients are on waiting lists are important. Although timely provision of joint replacements might be the preferred option, current economic and health system structures mitigate against this. The orthopedic waiting list population is likely to grow substantially in the near future with population aging and increased incidence of arthritis. In the meantime, interventions to reduce social and sex disparities and improve physical and psychological wellbeing are warranted.