title: Primary hip and knee replacement surgery: Ontario criteria for case selection and surgical priority.
abstract: OBJECTIVE
  To develop, from simple clinical factors, criteria to identify appropriate patients for referral to a surgeon for consideration for arthroplasty, and to rank them in the queue once surgery is agreed.
  
  
  METHODS
  Delphi process, with a panel including orthopaedic surgeons, rheumatologists, general practitioners, epidemiologists, and physiotherapists, who rated 120 case scenarios for appropriateness and 42 for waiting list priority. Scenarios incorporated combinations of relevant clinical factors. It was assumed that queues should be organised not simply by chronology but by clinical and social impact of delayed surgery. The panel focused on information obtained from clinical histories, to ensure the utility of the guidelines in practice. Relevant high quality research evidence was limited.
  
  
  METHODS
  Ontario, Canada.
  
  
  METHODS
  Appropriateness ratings on a 7-point scale, and urgency rankings on a 4-point scale keyed to specific waiting times.
  
  
  RESULTS
  Despite incomplete evidence panellists agreed on ratings in 92.5% of appropriateness and 73.8% of urgency scenarios versus 15% and 18% agreement expected by chance, respectively. Statistically validated algorithms in decision tree form, which should permit rapid estimation of urgency or appropriateness in practice, were compiled by recursive partitioning. Rating patterns and algorithms were also used to make brief written guidelines on how clinical factors affect appropriateness and urgency of surgery. A summary score was provided for each case scenario; scenarios could then be matched to chart audit results, with scoring for quality management.
  
  
  CONCLUSIONS
  These algorithms and criteria can be used by managers or practitioners to assess appropriateness of referral for hip or knee replacement and relative rankings of patients in the queue for surgery.
authors.affiliation: Departments of Medicine and Surgery, University of Toronto, Ontario, Canada.
authors.forename: C D
authors.initials: CD
authors.lastname: Naylor
authors.forename: J I
authors.initials: JI
authors.lastname: Williams
mesh_terms: D000465:Algorithms; D003697:Delphi Technique; D004813:Epidemiology; D005194:Family Practice; D006622:Hip Prosthesis / Q000592:standards*; D007720:Knee Prosthesis / Q000592:standards*; D009864:Ontario; D009985:Orthopedics; D010147:Pain Measurement; D018579:Patient Selection; D026741:Physical Therapy Modalities; D017410:Practice Guidelines as Topic; D011785:Quality Assurance, Health Care; D012017:Referral and Consultation; D012219:Rheumatology; D014850:Waiting Lists