Access to hip and knee replacement surgery in patients with chronic diseases according to patient-reported pain and functional status

Abstract

Background: An increasing number of patients undergoing hip or knee replacement have chronic diseases. It has been suggested that the presence of chronic diseases may affect access to this type of surgery in the English National Health Service (NHS). We examined the access to hip and knee replacement surgery in patients with and without chronic diseases according to preoperative patient-reported pain, functional status and symptom duration. Methods: We analysed data of 640,832 patients who had hip or knee surgery between 2009 and 2016 in England. Multivariable regression was used to estimate the impact of 11 chronic diseases on severity of joint problems as measured on a scale from 0 to 48 by Oxford Hip (OHS) and Knee Scores (OKS) just before surgery and on likelihood of long-standing joint problems (> 5 years pre-operatively). Results: Patients with chronic diseases reported more severe joint problems than patients without (OHS differences ranged from 1.1 [95% CI 0.93, 1.2] to 2.5 [95% CI 2.3, 2.7] and OKS differences from 0.5 [95% CI 0.3, 0.7] to 2.6 [95% CI 2.4, 2.7] for the 11 chronic diseases) but the differences remain small. When analysed separately, patients with chronic diseases reported both more severe pain and poorer functional status. Six chronic diseases in hip patients and two in knee patients increased the likelihood that they had long-standing joint problems. The severity of joint problems just before surgery increased with the number of chronic diseases (OHS differences; one chronic disease (1.5 [95% CI 1.4, 1.5]) to four or more (5.8 [95% CI 5.6, 6.0])). Conclusions: Patients with chronic diseases reported more severe joint problems immediately before hip or knee replacement surgery suggesting they have hip or knee replacement later in the course of their joint disease.

Impact of comorbidities on the safety and effectiveness of hip and knee arthroplasty surgery

“…In the UK, our previous work on severity of functional status before hip and knee replacement surgery found that patients with comorbidities had more severe pain and poorer functional status just before surgery than patients without comorbidities 36 . When we looked at unpublished data to compare those commissioning regions with restrictive policies to access hip or knee replacement surgery against those that do not have restrictive policies we found little evidence that at the moment in practice patients are being denied surgery.…”

Temporal trends in comorbidity in adult elective hip and knee arthroplasty patients in England

“…4 However, patients with end-stage OA and comorbidities have longer waiting times until surgery, 5 and have more severe joint problems at the time of their surgery compared with patients with fewer or no comorbidities. 6 The presence of comorbidities is associated with more complex clinical management of arthroplasty patients and worse health outcomes. 7,8 It is a predictor of perioperative and in-hospital mortality, 9 and a risk factor for 90-day postoperative mortality.…”

Comorbidities do not limit improvement in pain and physical function after total knee arthroplasty in patients with knee osteoarthritis: the BEST-Knee prospective cohort study

“… 12 A further limitation of prior studies is that they have largely focused on the level of joint pain or physical function achieved after TKA rather than improvement from preoperative levels. This detail is critical as the presence of comorbidities has been linked with worse levels of OA pain and function prior to TKA, 13 in other words, a lower starting point. Given the known impact of comorbidities on presurgical status, a focus on their ‘journey’ (improvement) may be as important as their ‘destination’ (final absolute level attained).…”