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Australian Health Review Australian Health Review Society
Journal of the Australian Healthcare & Hospitals Association
RESEARCH ARTICLE (Open Access)

Snakes and ladders: the barriers and facilitators of elective hip- and knee-replacement surgery in Australian public hospitals

Julie L. Walters A , Shylie F. Mackintosh A and Lorraine Sheppard A B
+ Author Affiliations
- Author Affiliations

A School of Health Sciences, University of South Australia, Adelaide, SA 5000, Australia. Email: shylie.mackintosh@unisa.edu.au; lorraine.sheppard@unisa.edu.au

B Corresponding author. Email: julie.walters@unisa.edu.au

Australian Health Review 37(2) 166-171 https://doi.org/10.1071/AH12177
Submitted: 4 May 2012  Accepted: 18 October 2012   Published: 18 March 2013

Journal Compilation © AHHA 2013

Abstract

Objectives. Waiting lists for elective surgery are a persistent problem faced by health systems. The progression through elective surgery waiting lists can be likened to a game of snakes and ladders where barriers (snakes) delay access to surgery and facilitators (ladders) expedite access. The aim of the present study was to describe the barriers and facilitators to delivery of total hip- and total knee-replacement surgery in South Australian public-funded hospitals.

Methods. Semistructured interviews with staff, direct observation of administrative processes and documentation analysis were combined under a systems theory framework.

Results. System barriers (snakes) were grouped into five categories: resources, workload, hospital engagement, community engagement and system processes. Inadequate resources was the most prominent barrier, patient cancellations resulted in one-third of administrative tasks being repeated and there was a perceived lack of engagement to maximising efficiency. Interestingly, despite a lack of resources being perceived to be the biggest problem, additional resources without system change was not considered an effective long-term strategy.

Conclusions. Given the complexity of the elective surgery system, it is not surprising that single-item reforms have not created lasting reductions in waiting times. Multifaceted, whole-system reforms may be more successful.

What is known about the topic? Waiting lists and waiting times for surgery are controversial, associated with frequent reforms and negative emotive headlines. We know from existing literature and anecdotal reports that individuals frequently experience lengthy delays before receiving elective surgery. Anecdotal reports also suggest that there are inefficiencies within elective surgery systems that contribute to these delays and result in cancellations, patient deterioration and poor overall satisfaction with the public health system in Australia. What isn’t clear is whether this perception is accurate and what inefficiencies do exist that could be specifically targeted for reform.

What does this paper add? This paper adds weight to the argument that some inefficiencies exist within elective surgery systems, and identifies specific barriers to the delivery of total hip- and total knee-replacement surgery in South Australian public hospitals. It also identifies several strategies that could improve system function, some of which have already been implemented at a local level in response to stress on the system, and some of which require broad region- or state-wide change. In contrast to existing research, the level of detail provided in the present paper should allow for targeted reforms with the potential to improve system function and the efficiency with which joint-replacement surgery can be delivered.

What are the implications for practitioners? All clinicians aim to provide the best intervention for their patients. Should the findings of this study be used to inform elective surgery system changes, patients and clinicians should experience a more streamlined approach to referral for and receipt of elective surgery in public hospitals. The consistency with which barriers and facilitators were identified across the four hospitals involved in this research supports the generalisability of the results. This further suggests that although specific to hip and knee replacement, many of the same barriers and facilitators could be in place across numerous surgical and non-surgical disciplines.


References

[1]  Bedo S. Surgery wait list to blow out on Gold Coast. The Gold Coast News 2012 February 5.

[2]  Gartland F. Orthopaedic waiting lists surge as nurses retire. Irish Times 2012 January 16.

[3]  Campbell D, Ball J. Number of NHS patients missing, waiting time target soars. The Guardian 2012 January 19.

[4]  Gentry C. Waiting list: dilemma for Medicaid. Health News Florida 2012 January 8.

[5]  Stoop AP, Vrangbæk K, Berg M. Theory and practice of waiting time data as a performance indicator in health care: a case study from The Netherlands. Health Pol 2005; 73(1): 41–51.

[6]  Mahon JL, Bourne RB, Rorabeck CH, Feeny DH, Stitt L, Webster-Bogaert S. Health-related quality of life and mobility of patients awaiting elective total hip arthroplasty: a prospective study. CMAJ 2002; 167 1115–21.

[7]  Mascarenhas R. The Manitoba arthroplasty waiting list: impact on health-related quality of life and initiatives to remedy the problem. J Eval Clin Pract 2009; 15 208–11.
The Manitoba arthroplasty waiting list: impact on health-related quality of life and initiatives to remedy the problem.Crossref | GoogleScholarGoogle Scholar |

[8]  Australian Government Department of Health and Ageing. The state of our public hospitals. Report. Canberra: Australian Government Department of Health and Ageing; 2009.

[9]  Sheldon T. Dutch waiting lists increase despite £36m campaign. BMJ 2000; 321 530
Dutch waiting lists increase despite £36m campaign.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3cvmvF2itw%3D%3D&md5=28d764604578755c9e4a9d4ac39a845dCAS |

[10]  Hanning M, Spangberg UW. Maximum waiting time − a threat to clinical freedom? Implementation of a policy to reduce waiting times. Health Policy 2000; 52 15–32.
Maximum waiting time − a threat to clinical freedom? Implementation of a policy to reduce waiting times.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3M%2FgsFGktw%3D%3D&md5=18dab3312febf66f87f1b9b411a33069CAS |

[11]  Bassi RS, Haidar SG, Gupta AK, Sinha AK, Deshmukh SC. Can single-stop carpal tunnel syndrome assessment clinics reduce waiting time to surgery? Clinical Governance 2004; 9 222–4.
Can single-stop carpal tunnel syndrome assessment clinics reduce waiting time to surgery?Crossref | GoogleScholarGoogle Scholar |

[12]  Smith J, Rudd C. Streamlining pre-operative assessment in orthopaedics. Nurs Stand 1998; 13 45–7.
| 1:STN:280:DyaK1M%2FmsVaguw%3D%3D&md5=d7f8897c8a9bf14375e68df56321e5f2CAS |

[13]  Gauld R, Derrett S. Solving the surgical waiting list problem? New Zealand’s ‘Booking System’. Int J Health Plann Manage 2000; 15 259–72.
Solving the surgical waiting list problem? New Zealand’s ‘Booking System’.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3M7lvFOgsw%3D%3D&md5=ec19e3011fc8514dc7d5f3af91f36a6aCAS |

[14]  Singh N, Brooke-Cowden GL, Whitehurst C, Smith D, Senior J. The auburn elective surgery pilot project. ANZ J Surg 2005; 75 768–75.
The auburn elective surgery pilot project.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2MrgtFygsw%3D%3D&md5=82335e6b06599b62bf67ceaa70150e1bCAS |

[15]  MacCormick AD, Tan CP, Parry BR. Priority assessment of patients for elective general surgery: game on? ANZ J Surg 2004; 74 143–5.
Priority assessment of patients for elective general surgery: game on?Crossref | GoogleScholarGoogle Scholar |

[16]  Escobar A, Quintana JM, González M, Bilbao A, Ibanez B. Waiting list management: priority criteria or first-in first out? A case for total joint replacement. J Eval Clin Pract 2009; 15 595–601.
Waiting list management: priority criteria or first-in first out? A case for total joint replacement.Crossref | GoogleScholarGoogle Scholar |

[17]  MacCormick AD, Collecutt WC, Parry BR. Prioritizing patients for elective surgery: a systematic review. ANZ J Surg 2003; 73 633–42.
Prioritizing patients for elective surgery: a systematic review.Crossref | GoogleScholarGoogle Scholar |

[18]  Kingston R, Carey M, Masterson E. Need-based waiting lists for hip and knee arthroplasty. Ir J Med Sci 2000; 169 125–6.
Need-based waiting lists for hip and knee arthroplasty.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3cvlt1Sjuw%3D%3D&md5=891c79972d2283bcb334c0be1c7358a7CAS |

[19]  Lack A, Edwards RT, Boland A. Weights for waits: lessons from Salisbury. J Health Serv Res Policy 2000; 5 83–8.
| 1:STN:280:DC%2BD3M%2FgsVGgtA%3D%3D&md5=e20fbddf5d0d81329be5afdeba1ef8f2CAS |

[20]  Street A, Duckett S. Are waiting lists inevitable? Health Policy 1996; 36 1–15.
Are waiting lists inevitable?Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK283gslKisg%3D%3D&md5=a8718e288947ffd28b7ef44bc32c91d4CAS |

[21]  Grbich C. Qualitative Research in Health. An Introduction. St. Leonards: Sage Publications; 1999.

[22]  Braun V, Victoria C. Using thematic analysis in psychology. Qual Res Psychol 2006; 3 77–101.
Using thematic analysis in psychology.Crossref | GoogleScholarGoogle Scholar |

[23]  Patton MQ. Qualitative Research and Evaluation Methods. 3rd edn. Thousand Oaks: Sage Publications; 2002.

[24]  Curtis AJ, Wolfe R, Russell COH, Costello AJ, Travis DG, Snow R, et al Prioritizing patients for prostatectomy: balancing clinical and psychosocial factors. ANZ J Surg 2007; 77 112–7.
Prioritizing patients for prostatectomy: balancing clinical and psychosocial factors.Crossref | GoogleScholarGoogle Scholar |

[25]  Briggs RJ, Smith KM, Dejager EM, Callahan JT, Abernethy JA, Dunn EJ, et al The active management of surgical waiting lists: a urological surgery case study. Aust Health Rev 2011; 35 399–403.

[26]  Oldmeadow LB, Bedi HS, Burch HT, Smith JS, Leahy ES, Goldwasser M. Experienced physiotherapists as gatekeepers to hospital orthopaedic outpatient care. Med J Aust 2007; 186 625–8.

[27]  Blackburn MS, Cowan SM, Cary B, Nall C. Physiotherapy-lead clinic for low back pain. Aust Health Rev 2009; 33 663–70.
Physiotherapy-lead clinic for low back pain.Crossref | GoogleScholarGoogle Scholar |

[28]  Walters JL, Mackintosh SF, Sheppard L. The journey to total hip or knee replacement. Aust Health Rev 2012; 36 130–5.
The journey to total hip or knee replacement.Crossref | GoogleScholarGoogle Scholar |

[29]  Cipriano LE, Chesworth BM, Anderson CK, Zaric GS. An evaluation of strategies to reduce waiting times for total joint replacement in Ontario. Med Care 2008; 46 1177–83.
An evaluation of strategies to reduce waiting times for total joint replacement in Ontario.Crossref | GoogleScholarGoogle Scholar |

[30]  Patterson V, Humphreys J, Henderson M, Crealey G. Email triage is an effective, efficient and safe way of managing new referrals to a neurologist. Qual Saf Health Care 2010; 19 e51
Email triage is an effective, efficient and safe way of managing new referrals to a neurologist.Crossref | GoogleScholarGoogle Scholar |