Correspondence

Knee-Replacement Surgery in the United States and Ontario

N Engl J Med 1995; 332:822-823March 23, 1995

Article

To the Editor:

To a Canadian rheumatologist, Coyte et al.'s description of rapid access to orthopedic surgeons and subsequent knee-replacement surgery (Oct. 20 issue)1 seems utopian. Imagine my surprise on finding that the description was of my own country. In Edmonton, Alberta, my patients wait a minimum of three months to see a surgeon. One surgeon even keeps a separate office waiting list for patients before they start the formal wait of three or four months.

I surveyed 12 patients admitted during the previous three weeks for joint-replacement surgery (hip and knee). All had waited for more than a year. It remains possible that Ontario is a utopian oasis, but I think it more likely that the results of the study by Coyte et al. reflect a boom in Ontario (1985 through 1989), when money, doctors, and beds were readily available — a time in Canada that is clearly gone forever.

A.S. Russell, F.R.C.P.(C.)
University of Alberta, Edmonton, AB T6C 2S2, Canada

1 References

1. 1

   Coyte PC, Wright JG, Hawker GA, et al. Waiting times for knee-replacement surgery in the United States and Ontario. N Engl J Med 1994;331:1068-1071
   Full Text | Web of Science | Medline

To the Editor:

I think Coyte et al. used flawed methods in their study, specifically with respect to the administrative data. Only the patients with arthritis in their knees who actually underwent knee replacement, rather than some other procedure, were included in the analysis.

When I was a fellow in knee surgery at the University of Toronto in 1985, the practice was to perform many other procedures as alternatives to knee replacement, such as high tibial osteotomy or arthroscopic débridement and lavage for osteoarthritis. It was also the practice of the Ontario Health Insurance Plan to ration the number of knee-replacement procedures that each hospital was allowed to perform during the course of a year. Accordingly, at the beginning of a calendar year patients with a diagnosis of osteoarthritis were more likely to undergo knee replacement, but at the end of the year, patients with this diagnosis were more likely to undergo either osteotomy or arthroscopy. Because patients with similar diagnoses may receive different treatments in Canada and the United States, a comparison of the waiting times for surgery in the two countries may be misleading.

Dennis J. Sullivan, M.D.
100 Foden Rd., South Portland, ME 04106-2387

Author/Editor Response

The authors reply:

To the Editor: Dr. Russell suggests that the shorter waiting times reported in our study, as compared with his experience, may reflect specific characteristics of Ontario during the second half of the 1980s. Health expenditures in Ontario increased at an average annual rate of 11.2 percent during the period from 1982–1983 to 1992–1993. This was more than twice the rate of inflation and almost 50 percent higher than the rate of growth in health expenditures elsewhere in Canada.1 Even during the period of our study, however, doctors and patients were concerned about waiting times for joint-replacement surgery. Furthermore, as we reported, the waiting times at teaching hospitals were more than 50 percent longer than the times at nonteaching hospitals. It is our view that the waiting times reported by physicians at teaching hospitals, such as those reported by Dr. Russell, are not representative of the waiting period for all patients in the province.

In response to Dr. Sullivan, the Ontario Health Insurance Plan is responsible only for reimbursing physicians for claims on a fee-for-service basis. The Institutional Services Branch of the Ontario Ministry of Health provides hospitals with a prospective global budget. Individual hospitals have the discretion to allocate their funds and to perform as many or as few joint replacements as they wish. Thus, the government is not directly involved in the rationing of joint-replacement surgery in Ontario.

Of the 16,218 knee replacements performed between 1985 and 1990, 25.1 percent were performed in the first three months of the fiscal year, and 24.5 percent in the last three months. Although the average rate of tibial osteotomy was two to three times higher in Ontario than in the United States,2 the low incidence of this procedure as compared with knee-replacement surgery (a ratio of 1 to 10) suggests that relatively few patients undergo osteotomy as an alternative procedure. Although the use of alternative therapies is a potential limitation in comparing waiting times, we believe it is unlikely that this factor significantly affected our results.

Peter C. Coyte, Ph.D.
University of Toronto, Toronto, ON M5S 1A8, Canada

James G. Wright, M.D., M.P.H.
Hospital for Sick Children, Toronto, ON M5G 1X8, Canada

2 References

1. 1

   Health Canada, Health Information Division. “Green book tables”: Provincial Government health expenditures and related federal contributions: Canada, the provinces and the territories, 1974-75 to 1992-93. Ottawa, Ont.: Ministry of Supply and Services Canada, July 1994.
   

2. 2

   Heck DA, Coyte PC, Dittus R, et al. Utilization of tibial osteotomy in the United States and Ontario, Canada, in the elderly patient. Orthop Trans 1994;17:1076-1077 abstract.