The ongoing impact of orthopaedic wait times

Orthopaedic surgical wait times consistently fail to meet Canadian benchmarks. In 2021, the Canadian Institute for Health Information reported that only 65% of hip replacements and 59% of knee replacements met wait-time standards.[1] Lengthy wait times are associated with decreased health-related quality of life, increased pain severity, and decreased patient satisfaction with primary and specialist care.[2] Increased wait times are also associated with longer hospital stays and greater service cost.[3]

Despite federal and provincial government funding and growing patient advocacy focused on the lived experience of waiting for surgery (e.g., the Wait Time Alliance), the percentage of British Columbians receiving knee replacement surgery within recommended time frames has improved by less than 5% since 2016.[4] Referral models exist to reduce wait times and include components such as standardized referral forms with single-entry, multidisciplinary triage and inclusion of conservative treatments.[2-4] These models report high professional satisfaction and orthopaedic surgical conversion rates. New initiatives to tackle orthopaedic wait times must be evidence informed and codesigned with local health professionals.

The Shared Orthopaedic Referral and Triage project

The Shared Orthopaedic Referral and Triage (SORT) project is a 2-year Shared Care Committee initiative facilitated by the East Kootenay Division of Family Practice. Guided by orthopaedic surgeons, family physicians, sport medicine physicians, and physiotherapists, SORT aims to:

• Describe local referral pathways.
• Design and implement a standardized referral form.
• Increase awareness and uptake of conservative treatments, including educational resources.

Describing the East Kootenay referral pathway

SORT conducted 25 semi-structured interviews with physicians, clinic managers, and physiotherapists, with a cross-sectional survey of orthopaedic surgeons and family physicians (n = 89, 70% response). Six weeks of referral data were retrospectively extracted from five clinics. Locally, approximately 330 nonemergency orthopaedic referrals are made monthly. Most family physicians (63%) reported not using a referral form, and orthopaedic surgeons reported a substantial proportion of referrals (55%) were missing clinical details or had incomplete or out-of-date imaging. Additionally, orthopaedic surgeons reported most patients (67%) would have benefited from sport medicine physician referrals; comparatively, family physicians reported a smaller proportion (26%) would have benefited. Approximately 54% of family physicians disagreed that patient flow was coordinated.

Codesigning a standardized, practice-ready referral form

SORT reviewed 15 orthopaedic referral forms; completed a literature review to identify potential triage tools; held group and individual meetings to iteratively review drafts; compared the drafts to a random sample of referral letters; and synthesized feedback from clinic managers, orthopaedic surgeons, and family physicians.

Most family physicians preferred standardized referral forms (71%) with the ability to indicate urgency (73%). Eight drafts were reviewed by 22 collaborators on at least two different occasions. The final SORT form includes:

• All orthopaedic surgeons and sport medicine physicians, with online links to service scope and wait times.
• Three items to explore urgency (e.g., impact and changes to daily living activities).
• Listings of conservative treatments with links to health authority–provided services (e.g., Primary Care Network physiotherapy).
• A link to consensus-driven imaging requirements for acute and chronic orthopaedic concerns.

Increasing awareness and uptake of conservative treatments, including patient education

Our physiotherapy advisory group independently scored Pathway resources across three dimensions: evidence-based, comprehensiveness, and patient acceptability. The validated Patient Education Materials Assessment Tool assessed actionability and understandability.[5] Materials including exercises were prioritized.

Before SORT, less than one-quarter of family physicians (23%) provided patient educational materials before making orthopaedic referrals. Of the 114 available resources, 27 met project thresholds for being evidence-based, patient acceptable, comprehensive, actionable, and understandable.

SORT preliminary outcomes

In April 2024, the SORT referral form, patient education, and imaging guidelines were distributed to family practices. In the first 2 months, there was a 26% increase in referrals to sport medicine physicians. The SORT care pathway is now the most viewed clinician tool locally. Pathways also highlighted 11 SORT-selected patient resources as provincial picks and added seven new resources. SORT collaborated with a specialty working group with the Provincial Health Services Authority to design standardized provincial content for orthopaedic e-referral via OceanMD, which features interoperability between medical records software, wait time reporting, and patient engagement.

SORT is ongoing, with final evaluation in January 2025. Current activities include best-practice casting procedures, educational videos with osteoarthritis decision aids, and refining emergency orthopedic referral pathways.
—Alex Chan, PhD, MD, FRCSC
Orthopaedic Surgeon, East Kootenay Regional Hospital
—Megan Ure, CCFP, CFPC, IOC Dip
Sports Medicine Family Physician, F.W. Green Clinic
—William Brown, MD, CCFP
Family Physician, East Kootenay Division of Family Practice
—Yvonne Keyzer, MD, FCFP, IOC Dip
Sports Medicine Family Physician, Creekside Physiotherapy
—Ryan Sleik, MSc
Physiotherapist, Kootenay Therapy Center
—Kari Loftsgard, BSc
Physiotherapist, Kootenay Therapy Center
—Jacqui van Zyl, MBChB
Program Manager, East Kootenay Division of Family Practice
—Kurtis Morrish, MD, CCFP, CAC SEM, CASEM Dip SEM, MSc, MPH
Sports Medicine Family Physician, University of British Columbia
—Elizabeth Fradgley, PhD
Project Lead, East Kootenay Division of Family Practice

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This article is the opinion of the Joint Collaborative Committees (JCCs) and has not been peer reviewed by the BCMJ Editorial Board.

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

References

1.    Canadian Institute for Health Information. Wait times for priority procedures in Canada, 2022. Accessed 10 September 2024. www.cihi.ca/en/wait-times-for-priority-procedures-in-canada-2022.

2.    Lizaur-Utrilla A, Martinez-Mendez D, Miralles-Muñoz FA, et al. Negative impact of waiting time for primary total knee arthroplasty on satisfaction and patient-reported outcome. Int Orthop 2016;40:2303-2307.

3.    Pincus D, Wasserstein D, Ravi B, et al. Medical costs of delayed hip fracture surgery. J Bone Joint Surg Am 2018;100:1387-1396.

4.    Marshall DA, Bischak DP, Zaerpour F, et al. Wait time management strategies at centralized intake system for hip and knee replacement surgery: A need for a blended evidence-based and patient-centered approach. Osteoarthr Cartil Open 2022;4:100314.

5.    Shoemaker SJ, Wolf MS, Brach C. Development of the Patient Education Materials Assessment Tool (PEMAT): A new measure of understandability and actionability for print and audiovisual patient information. Patient Educ Couns 2014;96:395-403.