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Waiting lists for orthopaedic surgery have bad — and good — points
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When I started in joint replacement in the late 1980s, my university clinic had a 3-year waiting time for total hip and knee replacements. As the clinic had a high reputation in Denmark, patients stayed on the list until surgery. During the 1990s and continuing in the new millennium, the need for shorter surgical waiting lists has been a powerful tool used by politicians – usually to gain votes. No one would deny that orthopaedic surgery should not be delayed when it is indicated and decided as the best option to relieve pain and disability.
First local politicians and then governments gave guidelines to hospitals for handling orthopaedic cases so the waiting time for surgery would be shorter. This resulted in a health law in Denmark, which stated that, in public hospitals, patients should undergo surgery within 4 weeks of when it was decided that surgery is needed. In cases where it was not possible, patients could decide to undergo the surgery at a private clinic paid for by the government.
In the beginning, it was nearly impossible to comply with the 4-week limit. Several cases were moved to the private clinics, which led to the start-up of more private clinics, as well as the growth of existing ones.
Follow-up visits
The next step for the government bodies was to impose a law that effected the first preoperative visit after referral from the general practitioner. If a patient could not be examined within 4 weeks, then an appointment could be provided by a physician in a private clinic.
Just a few years after these laws went into effect, waiting lists for most orthopaedic surgical procedures more or less disappeared in Denmark. That only left spine surgery at issue, mainly due to limited numbers of spine surgeons in the country.
The upside of having short or even non-existent surgical waiting lists is patients can be treated as soon as possible, with some patients requesting surgery immediately, almost within days of their first visit with an orthopaedic surgeon. But, the downside of briefer, more manageable waiting lists is they pose difficulty in planning and executing a clinic’s surgical program. As most larger orthopaedic clinics are specialized, which meets the needs of patients who have asked to be treated only by specialists, surgeons frequently only handle a limited number of procedures outside their specialty. Therefore, it is not possible to shift a spine surgery case to a hip surgeon.
Moreover, in my specialty of hip replacement, a steady state has been reached in Denmark, meaning the total number of hip procedures performed per 100,000 inhabitants is no longer increasing. As we are able to meet the demand for hip arthroplasty, several public clinics now have an overcapacity for performing lower limb joint replacement and not enough cases scheduled. These clinics now face such issues as reduced productivity capacity, and possibly the need to reduce staff.
Several start-up private clinics have either closed or now have a low “production” capacity and it has been discussed whether the indications for joint replacement in both governmental and private clinics might change in response to the shortened waiting times, with surgeons performing total joint arthroplasty at an earlier stage in the disease process, just to fill up the operating theaters and preserve jobs.
Three-month delay OK
Consequently, the government has changed the law again so specified surgical procedures, including lower limb joint replacement, can now be delayed up to 3 months at public clinics before being transferred to a private clinic.
What is an acceptable wait time for elective orthopaedic surgery? Patients who require most types of routine orthopaedic surgery will not suffer if they wait 4 weeks to 8 weeks for it. During that waiting period they can mentally prepare themselves for the surgery and learn more about what to expect postoperatively. It is also possible that during the waiting period some patients will be “cured” or find they do not require surgery, or at least not right now. The waiting period also could give clinics needed time to create meaningful surgical programs for their patients. Ultimately, this approach could prevent short-term closures of certain lines of surgery within a clinic. But, for this to work, the number of joint replacement surgeries performed in the country must first be reduced noticeably.
Although this is just the Danish side of the surgical waiting list issue, it shows how the issue has changed in 3 decades. Its impact on public and private clinics has been both good and bad.
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- Per Kjaersgaard-Andersen, MD, is Chief Medical Editor of Orthopaedics Today Europe. He can be reached at Orthopaedics Today Europe, 6900 Grove Road, Thorofare, NJ 08086, USA; email: orthopaedics@healio.com.
Disclosure: Kjaersgaard-Andersen has no relevant financial disclosures.