Feb 112014

‘Optimal’ Waiting Time: Why 14 Weeks?

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Waiting time for hip and knee replacements is a hot topic in Alberta and across the country. The quality of care for hip and knee replacement patients in Alberta has been fundamentally transformed over the past decade, including improved access to care for hip and knee replacement patients. In Alberta, we are currently in year three of a five-year plan to reduce waiting time for 90% of hip and knee replacement patients to 14 weeks from the date of decision to have surgery to the date of the surgery. We often receive questions about the wait time target – why 14 weeks? Here is some background about wait time target for hip and knee replacements in Canada and Alberta:

At the 2004 First Ministers’ meeting, the premiers and prime minister agreed to support the 10-Year Plan to Strengthen Health Care, a strategy to improve public health care across the country. This group acknowledged that timely access to care is a high priority for Canadians and must be made a national priority. First ministers committed to reducing wait times in five priority areas: cardiac surgery, vision restoration, hip and knee replacements, diagnostics, and cancer treatment.

In 2005, the first ministers set eight evidence-based national benchmarks (medically acceptable maximum wait times). These included 26 weeks for 90% of patients from surgical decision date to surgery for hip and knee replacements.

The same year, Alberta conducted a major pilot project to test a hip and knee care path designed by the Alberta’s orthopaedic surgeons and Alberta Bone and Joint Health Institute. The new care path set an optimal wait time range of 4 to 16 weeks.

During the pilot, all patients who followed the new care path received surgery within 16 weeks of their decision date. But the pilot was conducted in a controlled environment intended to put the care path to the test. In the controlled atmosphere created for the pilot, there were no surgery backlogs or day-to-day operational issues. Recognizing that in the real world backlogs exist and day-to-day operational issues crop up, the target wait time range was extended to 4 to 20 weeks.

In 2010, Alberta Health and Wellness established Tier 1 Measures to reduce waiting time for hip and knee replacement surgery to a maximum of 14 weeks. The plan stated that these wait time targets are among the most progressive in Canada1.

The rationale for the 14-week target was based largely on a patient-centric perspective:

  • Studies indicated an increase in pain and loss of function in patients who wait longer than three months2-5.
  • Desmeules et al6 found a significant increase in pain in the opposite joint for patients who wait longer than six months.
  • Mahon et al7 reported losses in mobility and in health-related quality of life for patients who wait over 6 months.

Wait times are a necessary part of planning for hip and knee replacements. A wait time of zero is not desirable because patients need time to prepare for their surgery. Factors related to patient readiness (medical, surgical, functional) need to be addressed prior to surgery. The length of time it takes to become optimally ready varies drastically from patient to patient depending on these factors. The reality is there is not a wealth of evidence to say how long patients ‘should’ wait. We know there is a period of time  patients require to ensure they are ready and optimized for surgery. During this time, patients in Alberta receive comprehensive assessments from appropriate health care providers, prepare their home and support for when they return home after surgery and are taught everything they need to know to ensure a full, healthy recovery. Once patients are fully prepared and ready for surgery, the maximum time a patient should wait is dependent on the severity of their disease and their pain and functional status, which can be variable by individual patient.

In 2012, Alberta’s Hip & Knee Clinical Committee, the committee responsible for approving changes to the care path, discussed whether the wait time in the care path should be consistent with the provincial target of 14 weeks. The committee determined that it would be appropriate to be consistent with the provincial target, given the evidence available.

Alberta continues to enhance the quality of care for hip and knee replacement patients in Alberta, including access to care. Several strategies have been implemented  to ensure success, and great strides have been made. Recent results of these efforts are summarized here.

References:

1. Becoming the Best: Alberta’s 5-Year Health Action Plan (2010-2015). Retrieved from: http://www.health.alberta.ca/documents/becoming-the-best-2010.pdf

2. Conner-Spady, B., Estey, E., Arnett, G., Ness, K., McGurran, J., Bear, R., Noseworthy, T and the Steering Committee of the Western Canada Waiting List Project. Determinants of patient and surgeon perspectives on maximum acceptable waiting times for hip and knee arthroplasty. Journal of Health Services Research & Policy. Vol 10 No 2, 2005; 84-90.

3. Conner-Spady, B., G. Johnston, C. Sanmartin, J. McGurran, T. Noseworthy and the Saskatchewan Surgical Care Network/Western Canada Waiting List Project Research and Working Group Committee. 2007. “A Bird Can’t Fly on One Wing: Patient Views on Waiting for Hip and Knee Replacement Surgery.” Health Expectations10: 108-16.

4. Conner-Spady, B., Johnston, G., Sanmartin, C., McGurran, J., Noseworthy, T., and the Saskatchewan Surgical Care Network/Western Canada Waiting List Project Research and Evaluation Working Group Committee. Patient and Surgeon Views on Maximum Acceptable Waiting Times for Joint Replacement. Healthcare Policy. Vol 3 No 2, 2007; 102-116.

5. Conner-Spady, B., Sanmartin, C., Johnston, G., McGurran, J., Kehler, M., Noseworthy, T. ‘There are too many of us to fix.’ Patients’ views of acceptable waiting times for hip and knee replacements. Journal of Health Services Research & Policy. Vol 14 No 4, 2009. 212-218.

6. Desmeules F, Dionne CE, Belzile E, Bourbonnais R, Fremont P. The burden of wait for knee replacement surgery: effects on pain, function and health-related quality of life at the time of surgery. Rheumatology 2010, 49:945-954.

7. Mahon J.L., Bourne R.B., Rorabeck C.H., Feeny D.H., Stitt L., Webster-Bogaert S. Health-Related Quality of Life and Mobility of Patients Awaiting Elective Total Hip Arthroplasty: A Prospective Study. Canadian Medical Association Journal. 2002;167(10):1115–21.

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