title: Appropriateness of primary total hip and knee replacements in regions of Ontario with high and low utilization rates.
abstract: OBJECTIVE
  To compare the appropriateness of case selection for primary hip and knee replacements between two regions in Ontario: one with a high population-based utilization rate and one with a low rate.
  
  
  METHODS
  Random audit of medical records sampled from hospital discharge abstracts, with subsequent implicit and explicit criteria-based assessments of the appropriateness of surgery.
  
  
  METHODS
  People aged 60 years or over who underwent elective, single-joint, non-fracture-related, primary hip or knee replacement between Apr. 1, 1992, and Mar. 31, 1993, at one of seven hospitals in a high-rate region (comprising Brant, Huron and Oxford countries) or one of eight hospitals in a low-rate region (comprising the cities of Scarborough and Toronto).
  
  
  METHODS
  Structured review of hospital medical records, with additional review of information from surgeons and family physicians' office charts if necessary. Three physicians reviewed patient data and rated the preoperative pain level and functional status of patients, with agreement among at least two reviewers. The proportion of inappropriate cases was then assessed according to explicit criteria defined by a multidisciplinary panel using the delphi process. Profiles of each case were also subjected to independent implicit review by two rheumatologists and two orthopedic surgeons.
  
  
  METHODS
  Proportion of joint replacements deemed inappropriate in the high- and low-rate regions according to either the explicit criteria or the implicit review, as well as preoperative pain levels and functional status of patients in the high- and low-rate regions.
  
  
  RESULTS
  Hip replacements were more common among patients sampled in the low-rate region than among those in the high-rate region (57.3% v. 39.3%; p < 0.002), although the patients' baseline characteristics, including severity of preoperative pain and dysfunction, were otherwise similar between the regions. Inappropriate surgery, determined by explicit criteria, was equally uncommon in the two regions (6.4% and 6.1%). On implicit review, the two rheumatologists rated fewer cases as appropriate than did the two orthopedic surgeons (63.0% v. 80.0%; p < 0.001); however, the proportion of cases rated as inappropriate by the subspecialists was similar in the high- and low-rate regions (11.4% and 11.0%, respectively, by the rheumatologists, and 6.3% and 10.4%, respectively, by the orthopedic surgeons).
  
  
  CONCLUSIONS
  Patients selected for primary hip or knee replacement are similar in the high- and low-rate regions of Ontario. Inappropriate use of this procedure does not account for the high rate of surgery in some areas. Further studies will be required to determine which other factors account for the regional variations in the utilization rates and whether there is underservicing in low-rate areas.
authors.affiliation: Institute for Clinical Evaluative Sciences in Ontario (ICES), North York.
authors.forename: C V
authors.initials: CV
authors.lastname: van Walraven
authors.forename: J M
authors.initials: JM
authors.lastname: Paterson
authors.forename: M
authors.initials: M
authors.lastname: Kapral
authors.forename: B
authors.initials: B
authors.lastname: Chan
authors.forename: M
authors.initials: M
authors.lastname: Bell
authors.forename: G
authors.initials: G
authors.lastname: Hawker
authors.forename: J
authors.initials: J
authors.lastname: Gollish
authors.forename: J
authors.initials: J
authors.lastname: Schatzker
authors.forename: J I
authors.initials: JI
authors.lastname: Williams
authors.forename: C D
authors.initials: CD
authors.lastname: Naylor
mesh_terms: D016009:Chi-Square Distribution; D005260:Female; D006622:Hip Prosthesis / Q000706:statistics & numerical data*; D006801:Humans; D007720:Knee Prosthesis / Q000706:statistics & numerical data*; D008297:Male; D008485:Medical Audit / Q000706:statistics & numerical data; D008875:Middle Aged; D009864:Ontario; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data; D010351:Patient Discharge / Q000706:statistics & numerical data; D011897:Random Allocation; D012040:Regional Health Planning / Q000706:statistics & numerical data