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Table 6 Results of studies exploring general access

From: Assessing demographic access to hip replacement surgery in the United Kingdom: a systematic review

Ref.

Study timeframe

Estimate of surgical need

Estimate of surgical provision

Socio-demographic domains

Conclusions

[27]

January 1997 to December 2007

n/a

Waiting time until hip replacement from initial specialist referral to surgery

- Age

- Gender

- Area-based deprivation (Carstairs index of deprivation)

- Rurality of patient residence

- Provider of care (private, foundation trust, teaching hospital, specialist hospital, traditional NHS)

- Statistically significant reduction in waiting time with the following successive time periods:1997-2000, 2001-4, and 2005-7

Deprivation

- Positive association between deprivation and waiting times in 1997

- From 1997 to 2000, successive increases in deprivation quintile (least deprived ➔ most deprived) were associated with significant increase in waiting time by 1-2 weeks (P < 0.001)

- From 2001 to 2004, there was large variation in waiting time between deprivation quintiles with middle quintile patients waiting longest

- From 2005 to 2007, there was little association between deprivation quintile and waiting time

- Waiting times had more of a uniform distribution by 2007

- Variation in waiting time in relation to socioeconomic group decreased over time

[1]

SASH data: 1994 to 1995

ELSA data: March 2002 to March 2003

HES data: 2001/2 financial year

New Zealand score for joint disease severity (proxy score calculated from SASH and ELSA data)

Patients scoring below 48/80 on New Zealand score excluded

Admissions data from HES

- Age

- Gender

- Area-based deprivation (2004 IMD)

- Ethnic mix of patient residence

- Rurality

- Distance travelled to receive care

- Primary diagnosis

- Hospital variables (number of hip operations, orthopaedic training centre status, rate of consultants, and operating theatres

- Low provision to need ratio -- For every 1000 patients in need of surgery, 44 will be operated on

Deprivation

- In order to move to middle deprivation quintile, hospitals in most deprived quintile need to perform 24 additional surgeries per 1000 patients

- Patients in most deprived quintile had lower need to provision ratios than those in least deprived quintile (95% C.I: 0.30–0.33)

- Patients in most deprived quintile had 70% lower provision to need ratios than those in least deprived quintile

Geographical/Rurality

- Need to provision ratios lowest in north England, West Midlands and London

- Highest ratios in south England (except London)

- People in more rural areas (village/isolated) had highest need to provision ratios – longer road travel times also had greater provision

- Town and fringe areas had lowest need to provision ratios

Gender

- Men had lower need to provision ratios compared to women, receiving 8% more surgeries (95% C.I: 1.05–1.10)

Hospital effects

- Higher volume of surgeries, orthopaedic training centre status, more orthopaedic consultants and more operating theatres were associated with higher need to provision ratio

Ethnicity

- No effect on access seen with ethnic mix of patient residence

[30]

2001/2 financial year

n/a

Waiting time until hip replacement from initial specialist referral to surgery (calculated from HES data)

- Age

- Gender

- Area-based deprivation (2004 IMD)

- Number of diagnoses at hospital admission

- Primary diagnosis

- Hospital fixed effects

Deprivation

- Least deprived patients (educationally) wait 12.8 –13.6% less than patients from bottom 3 deprivation quintiles

- Most deprived patients (income) wait 7.5% longer than patients from the least deprived quintile

Age

- Patients over 75 years wait 17-30% less than patients aged 45-54

Gender

- Male patients wait 3.5% longer than women

Primary diagnosis

- Patients with rheumatoid arthritis or osteonecrosis experience shorter waiting times than arthrosis patients: 27% and 45-53% less respectively

Hospital effects

- 14% of waiting time variation are as a result of hospital-level differences

[35]

2002 to 2009

Hip replacement rates standardised (per area and per year) to national age-sex specific hip replacement rates for specific year

Admissions data from NHS hospitals

- Age

- Gender

- Area-based deprivation

- Mean rate of hip replacement for 2009: 20.2 per 10,000

Deprivation

- Patients from least deprived quintile receive 5.68 more hip replacements per 10,000 than the most deprived quintile (35% more likely) (95% CI: 5.18–6.18)

- Relative increase in age-sex adjusted inequality ratio from 1.23 to 1.35 between 2002 and 2009 (12% increase) (CI 1.25–1.45)

[36]

SMR data: April 1998 to March 2008

ISD data: financial year 2002/3 and 2007/8

n/a

Admissions and data on patient waiting times from SMR

- Age

- Gender

- Area-based deprivation (Scottish IMD 2006)

- Number of hip replacements increased by 42% from 4095 in 2002-2003 to 5829 in 2007-2008

- Proportion of NHS-funded surgeries undertaken in private hospitals rose from 1.1% in 2002-2003 to 2.9% in 2007-2008

Deprivation

- Most deprived quintile had least amount of hip replacements compared to least deprived

- 82.8 per 100,000 (95% C.I: 79.2–86.3) for most deprived in 1998-2003 versus 95.3 per 100,000 (95% C.I:91.5–99.0) for least deprived

- No significant change in socioeconomic inequality from 1998 to 2008 (p = 0.108)

Geographical

-Significant reduction in geographical inequality (p < 0.001) from 1998 to 2008

  1. NOTE: NHS = National Health Service; SASH = Somerset and Avon Survey of Health; ELSA = English Longitudinal Study of Ageing; HES = Hospital Episode Statistics; IMD = Indices of Multiple Deprivation; ECHO = European Collaboration for Healthcare Optimisation; SMR = Scottish Morbidity Records; ISD = Information Services Division; CI = confidence interval