In the JournalsPerspective

Total joint arthroplasty more common in Ontario than New York

Peter Cram

Patients in Ontario, Canada, demonstrated a higher rate of total knee and hip arthroplasty when compared with patients in New York, according to findings published in Arthritis and Rheumatology.

In addition, the researchers found that patients in Ontario were more likely to be discharged home, and less likely to be admitted to a rehabilitation facility.

Total joint replacement is a common surgical procedure and historically an expensive surgical procedure, and also in some ways a scarce resource,” Peter Cram, MD, MBA, of the University of Toronto and Toronto General Hospital, told Healio Rheumatology. “It’s interesting to think about how patient in different countries can access joint replacement, and we really wanted to compare joint replacement in Ontario and New York to see how these different countries handles these procedures.”

To compare the use and short-term outcomes of total joint arthroplasty (TJA) in the two adjacent regions, the researchers analyzed data from the New York State Inpatient Database, which includes administrative information for all patients admitted to acute care hospitals, except Veterans Administration and psychiatric facilities, and Ontario Discharge Abstract Data, which contains records on all hospitalizations paid for by the provincial health insurance plan.

Focusing on data from 2012 to 2013, the researchers compared the demographics, per-capita use and short-term outcomes of patients who underwent TJA.

According to the researchers, following direct standardization, per-capita use of total knee arthroplasty was 21.4 per 10,000 in Ontario, compared with 16.2 in New York (P < .001). Use of total hip arthroplasty was 11.5 per 10,000 in Ontario, compared with 10.5 in New York. However, researchers found that 75.5% of hospitals in New York performed TJA, compared with just 42.1% in Ontario.

“Perhaps the most surprising finding was that utilization of joint replacement was somewhat higher in Ontario, as compared to New York,” Cram said. “The typical headline is that there is rationing and wait lists in Canada. That is the common perception. The reality is that we found that there was greater utilization — more joint replacements being performed — in Ontario, which goes against the conventional wisdom regarding how health care in Canada is delivered.”

In addition, the researchers found that just 46.2% of patients from New York were discharged directly home, compared with 90% in Ontario (P < .001). Meanwhile, 30-day and 90-day readmission rates in New York were 4.6% and 8.4% respectively, compared to 3.9% and 6.7%, respectively, in Ontario.

“In other words, patients who had joint replacement in New York were more likely to go to an inpatient rehabilitation facility, and less likely to go home, as compared to patients in Ontario,” Cram said. “That is important because inpatient rehabilitation is very expensive. If you are asking, why health care is so expensive in the United States, rehab is a big reason.”

According to Cram, the findings suggest ways the U.S. health care system could save money.

“Ontario seems to be performing more joint replacements than New York, but that is balanced by the fact that patients in Ontario are more likely to be discharged home, and less likely to be readmitted,” Cram said. “What this means is that, you can see places where the United States could potentially cut down on their spending in some important ways. If you can discharge more people home, that’s less expensive, and if you can prevent some of those readmissions, which are more common in the United States, you can also save some money. This just hints at the challenges the U.S. health care system is facing.” – by Jason Laday

Disclosure: Cram reports no relevant financial disclosures.

Peter Cram

Patients in Ontario, Canada, demonstrated a higher rate of total knee and hip arthroplasty when compared with patients in New York, according to findings published in Arthritis and Rheumatology.

In addition, the researchers found that patients in Ontario were more likely to be discharged home, and less likely to be admitted to a rehabilitation facility.

Total joint replacement is a common surgical procedure and historically an expensive surgical procedure, and also in some ways a scarce resource,” Peter Cram, MD, MBA, of the University of Toronto and Toronto General Hospital, told Healio Rheumatology. “It’s interesting to think about how patient in different countries can access joint replacement, and we really wanted to compare joint replacement in Ontario and New York to see how these different countries handles these procedures.”

To compare the use and short-term outcomes of total joint arthroplasty (TJA) in the two adjacent regions, the researchers analyzed data from the New York State Inpatient Database, which includes administrative information for all patients admitted to acute care hospitals, except Veterans Administration and psychiatric facilities, and Ontario Discharge Abstract Data, which contains records on all hospitalizations paid for by the provincial health insurance plan.

Focusing on data from 2012 to 2013, the researchers compared the demographics, per-capita use and short-term outcomes of patients who underwent TJA.

According to the researchers, following direct standardization, per-capita use of total knee arthroplasty was 21.4 per 10,000 in Ontario, compared with 16.2 in New York (P < .001). Use of total hip arthroplasty was 11.5 per 10,000 in Ontario, compared with 10.5 in New York. However, researchers found that 75.5% of hospitals in New York performed TJA, compared with just 42.1% in Ontario.

“Perhaps the most surprising finding was that utilization of joint replacement was somewhat higher in Ontario, as compared to New York,” Cram said. “The typical headline is that there is rationing and wait lists in Canada. That is the common perception. The reality is that we found that there was greater utilization — more joint replacements being performed — in Ontario, which goes against the conventional wisdom regarding how health care in Canada is delivered.”

In addition, the researchers found that just 46.2% of patients from New York were discharged directly home, compared with 90% in Ontario (P < .001). Meanwhile, 30-day and 90-day readmission rates in New York were 4.6% and 8.4% respectively, compared to 3.9% and 6.7%, respectively, in Ontario.

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“In other words, patients who had joint replacement in New York were more likely to go to an inpatient rehabilitation facility, and less likely to go home, as compared to patients in Ontario,” Cram said. “That is important because inpatient rehabilitation is very expensive. If you are asking, why health care is so expensive in the United States, rehab is a big reason.”

According to Cram, the findings suggest ways the U.S. health care system could save money.

“Ontario seems to be performing more joint replacements than New York, but that is balanced by the fact that patients in Ontario are more likely to be discharged home, and less likely to be readmitted,” Cram said. “What this means is that, you can see places where the United States could potentially cut down on their spending in some important ways. If you can discharge more people home, that’s less expensive, and if you can prevent some of those readmissions, which are more common in the United States, you can also save some money. This just hints at the challenges the U.S. health care system is facing.” – by Jason Laday

Disclosure: Cram reports no relevant financial disclosures.

    Perspective
    Nelson F. SooHoo

    Nelson F. SooHoo

    In their study, Cram and colleagues present the finding that utilization of total joint replacement on a per-capita basis is similar or higher in Ontario when compared to the adjacent area in New York. This is initially surprising given that the single-payer Canadian system is assumed to have longer wait times compared to the less restrictive United States market. The researchers point out that the Canadian government has been working for over a decade to improve access and decrease wait times for joint replacement in light of studies from the early 2000s demonstrating 10-30% higher utilization in the United States. The current studies confirm these efforts have been successful.

    The results of this study suggest an answer to a question that has been important since Wennberg first reported small-area variation in health care utilization in Scientific American in 1982: When two areas with similar populations have different rates of utilization for a surgical procedure, which rate is right? We would like to know if high utilization reflects unnecessary care or low utilization indicates an underserved population.

    The study by Cram and colleagues indicates that for total joint replacement, the variation seen in the early 2000s was not due to over utilization in the U.S. but rather inadequate access in Canada. This is consistent with the excellent cost-effectiveness of total joint replacement and the expansion of care in Canada has helped Ontario make these benefits available at a rate similar to that in the U.S.

    • Nelson F. SooHoo, MD
    • Professor-in-residence Residency program director Department of orthopaedic surgery University of California Los Angeles

    Disclosures: SooHoo reports no relevant financial disclosures.