title: Patients' perceptions of joint replacement care in a changing healthcare system: a qualitative study.
abstract: BACKGROUND
  Ontario has introduced strategies over the past decade to reduce wait times and length of stay and improve access to physiotherapy for orthopaedic and other patients. The aim of this study is to explore patients' experiences of joint replacement care during a significant system change in their care setting.
  
  
  METHODS
  A secondary analysis was done on semi-structured qualitative interviews that were conducted in 2009 with 12 individuals who had undergone at least two hip or knee replacements five years apart at a specialized orthopaedic centre in Ontario, Canada. Interview transcripts were coded and then organized into themes.
  
  
  RESULTS
  Although the original study aimed to capture participants' experiences with changes in anaesthetic technique between their first and second joint replacements, the participants described several unrelated differences in the care they received during this period. For example, participants had difficulty obtaining a referral to an orthopaedic surgeon from their family physician. They also noted that the hospital stay and in-hospital physiotherapy they received were shorter after the second joint replacement surgery. They identified guidance from physiotherapists as an important component of their recovery, but sometimes had difficulty arranging physiotherapy after hospital discharge following their most recent surgery.
  
  
  CONCLUSIONS
  The changes described between the first and second joint replacements provide the participants' perspective on the impact of policy changes on wait times, reduced lengths of hospital stay and physiotherapy access. The impact of these policy changes, often made in an attempt to improve access to care, had an unintended and detrimental effect on participants' perceptions and experiences of the quality of care provided.
authors.affiliation: Department of Family and Community Medicine, University of Toronto, Toronto, ON.
authors.forename: Fiona
authors.initials: F
authors.lastname: Webster
authors.affiliation: Michael G. DeGroote School of Medicine, McMaster University Hamilton, ON.
authors.forename: Samantha
authors.initials: S
authors.lastname: Bremner
authors.affiliation: Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, ON.
authors.forename: Joel
authors.initials: J
authors.lastname: Katz
authors.affiliation: Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON.
authors.forename: Judy
authors.initials: J
authors.lastname: Watt-Watson
authors.affiliation: Holland Orthopaedic and Arthritic Centre, Sunnybrook Health Sciences Centre, Toronto, ON.
authors.forename: Deborah
authors.initials: D
authors.lastname: Kennedy
authors.affiliation: Acute Pain Service, North York General Hospital Toronto, ON.
authors.forename: Mona
authors.initials: M
authors.lastname: Sawhney
authors.affiliation: Department of Anaesthesia, Faculty of Medicine, University of Toronto, Toronto, ON.
authors.forename: Colin
authors.initials: C
authors.lastname: McCartney
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019644:Arthroplasty, Replacement, Hip / Q000534:rehabilitation*; D019645:Arthroplasty, Replacement, Knee / Q000534:rehabilitation*; D005260:Female; D018166:Health Care Reform; D006297:Health Services Accessibility; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009864:Ontario; D017060:Patient Satisfaction; D026741:Physical Therapy Modalities; D036301:Qualitative Research
references.citation: Jt Comm J Qual Improv. 1996 Sep;22(9):617-28
references.pmid: 8904690
references.citation: J Eval Clin Pract. 2010 Aug;16(4):724-30
references.pmid: 20545803
references.citation: Orthop Nurs. 2003 Nov-Dec;22(6):429-36
references.pmid: 14705473
references.citation: JAMA. 1996 Jan 10;275(2):152-6
references.pmid: 8531314
references.citation: Arch Orthop Trauma Surg. 2012 Jan;132(1):101-4
references.pmid: 21947286
references.citation: Arthritis Rheum. 2006 Oct;54(10):3212-20
references.pmid: 17009255
references.citation: Soc Sci Med. 2006 Jun;62(12):3157-60
references.pmid: 16377045
references.citation: Arch Gerontol Geriatr. 2005 Sep-Oct;41(2):169-76
references.pmid: 16085068
references.citation: J Arthroplasty. 2011 Dec;26(8):1418-26.e1-2
references.pmid: 21277159
references.citation: BMC Musculoskelet Disord. 2011 Feb 09;12:43
references.pmid: 21306615
references.citation: Orthopedics. 2009 Mar;32(3):167
references.pmid: 19309064
references.citation: BMC Health Serv Res. 2009 Mar 31;9:56
references.pmid: 19335904
references.citation: Reg Anesth Pain Med. 2011 Sep-Oct;36(5):461-5
references.pmid: 21857265
references.citation: Ann Surg. 2008 Aug;248(2):189-98
references.pmid: 18650627
references.citation: Am J Nurs. 2008 May;108(5):54-63; quiz 63-4
references.pmid: 18434802
references.citation: CMAJ. 2005 Jan 18;172(2):166
references.pmid: 15655231
references.citation: Can J Anaesth. 2011 Oct;58(10):902-10
references.pmid: 21822756
references.citation: Int J Rehabil Res. 2012 Jun;35(2):94-101
references.pmid: 22561215
references.citation: Phys Ther. 2003 Aug;83(8):696-706
references.pmid: 12882610
references.citation: Can J Surg. 2009 Aug;52(4):283-290
references.pmid: 19680512
references.citation: Health Expect. 2009 Jun;12(2):130-7
references.pmid: 19320753
references.citation: Clin Rehabil. 2009 Dec;23(12):1067-77
references.pmid: 19864466
references.citation: Ann R Coll Surg Engl. 2011 Jan;93(1):71-5
references.pmid: 21418755
references.citation: J Arthroplasty. 2012 Jun;27(6):851-6
references.pmid: 22386604