title: Evaluating the primary-to-specialist referral system for elective hip and knee arthroplasty.
abstract: OBJECTIVE
  Persistently long waiting times for hip and knee total joint arthroplasty (TJA) specialist consultations have been identified as a problem. This study described referral processes and practices, and their impact on the waiting time from referral to consultation for TJA.
  
  
  METHODS
  A mixed-methods retrospective study incorporating semi-structured interviews, patient chart reviews and observational studies was conducted at three clinic sites in Alberta, Canada. A total of 218 charts were selected for analysis. Standardized definitions were applied to key event dates. Performance measures included waiting times percentage of referrals initially accepted. Voluntary (patient-related) and involuntary (health system-related) waiting times were quantified.
  
  
  RESULTS
  All three clinics had defined, but differing, referral processing rules. The mean time from referral to consultation ranged from 51 to 139 business days. Choosing a specific surgeon for consultation rather than a next available surgeon lengthened waits by 10-47 business days. Involuntary waiting times accounted for at least 11% of total waiting time. Approximately 40-80% of the time patients with TJA wait for surgery was in the consultation period. Fifty-four per cent of new referrals were initially rejected, prolonging patient waits by 8-46 business days.
  
  
  CONCLUSIONS
  Our results suggest that variation in referral processing led to increased waiting times for patients. The large proportion of total wait attributable to waiting for a surgical consultation makes failure to measure and evaluate this period a significant omission. Improving referral processes and decreasing variation between clinics would improve patient access to these specialist referrals in Alberta.
authors.affiliation: Departments of Community Health Sciences and Medicine, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Ken
authors.initials: K
authors.lastname: Fyie
authors.forename: Cy
authors.initials: C
authors.lastname: Frank
authors.forename: Tom
authors.initials: T
authors.lastname: Noseworthy
authors.forename: Tanya
authors.initials: T
authors.lastname: Christiansen
authors.forename: Deborah A
authors.initials: DA
authors.lastname: Marshall
mesh_terms: D000416:Alberta; D019644:Arthroplasty, Replacement, Hip / Q000706:statistics & numerical data*; D019645:Arthroplasty, Replacement, Knee / Q000706:statistics & numerical data*; D017558:Elective Surgical Procedures / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000458:organization & administration / Q000706:statistics & numerical data; D006801:Humans; D009985:Orthopedics; D058007:Physicians, Primary Care; D012017:Referral and Consultation / Q000458:organization & administration* / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013997:Time Factors; D014850:Waiting Lists
keywords: hip and knee arthroplasty; quality of health care; referral and consultation; waiting lists; waiting times