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Persistent Inequalities in Access to Joint Replacement Surgery

Despite a years-long effort by the NHS to reduce social inequalities in the provision of joint replacement surgery, the gap between social

deprivation groups has remained constant over time, according to new research led by the University of Bristol.

The study, published in PLOS Medicine, correlated data from the National Joint Registry on hip and knee surgeries over a 10-year period with Office for National Statistics official population statistics to investigate inequalities in provision of joint replacement for osteoarthritis. 

Researchers identified all primary hip and knee replacements for osteoarthritis between 2007 and 2017 in England, comprising 675,342 hip and 834,146 knee replacements. They then merged this data with index of multiple deprivation figures for 2015 to identify the relative level of deprivation of the areas where patients lived.

Rate of Both Operations Increased by a Third 

Over the 10-year period, the overall rate of hip replacement increased

from 27 to 36 per 10,000 person-years, with equivalent figures for knee replacement increasing from 33 to 46. Yet inequalities of provision between the most and least affluent areas remained constant for both joints, with the most deprived areas having a hip surgery rate ratio of 0.58 in 2007 and 0.59 in 2017. Equivalent knee figures were 0.82 in 2007 and 0.81 in 2017.

The team reported: "Despite an overall improvement in the numbers of operations performed and less geographical variation in rates of surgery, inequalities between the most and least affluent areas remained large." Furthermore, these inequalities had "remained fairly constant".

They noted that joint replacements are cost-effective elective surgeries that are frequently performed in developed settings around the world. As populations age and obesity rises, the need for these surgeries is likely to increase, and people living in the most deprived areas have the greatest need for surgery.

The authors pointed out that such surgeries place an increasing public health burden on healthcare systems, and that inequalities were reported in the UK over a decade ago. NHS England tried to address this, in part by delivering part of its publicly funded orthopaedic activities within the private sector, however, with growing financial strain in the NHS, the current picture was "unclear".

The team concluded: "Care providers must take further action to address variation in access to these frequently performed operations."

Knee Replacement Disparities Observed Only for Private Procedures

Their study showed that for knee replacement, the social deprivation inequalities were observed only for privately funded procedures; whereas for hip replacement, evidence of disparities was observed for both publicly and privately funded procedures.

"These findings could help healthcare commissioners to identify how joint replacement provision should be provided in the NHS, to best address these disparities," the authors said. 

A study limitation was that certain important domains, such as ethnicity, were not investigated.

First author Erik Lenguerrand, a medical statistician at the University of Bristol, said: "Our study has shown that over the last decade socioeconomic inequalities in access to hip and knee replacement surgery remain wide, where those living in the most deprived areas have the least access to this surgery, even though they have the greatest clinical need."

Shantel Irwin, CEO of Arthritis Action, commented to Medscape News UK: "Unfortunately, people with joint conditions in lower socioeconomic areas experience pain for longer before receiving an official diagnosis, are more likely to give up work, and less likely to receive the support they need. 

"Policy leaders and healthcare organisations, including charities, Government, and the NHS, need to do more to spread information and resources to lower socioeconomic areas in an accessible way. Ways to do this can include distributing leaflets in local areas, more community outreach, or sharing information in more ways than just online for those with low tech literacy."

Funding for this study was conducted as part of the contract between the University of Bristol and HQIP-NJR to provide statistical support for the activities of the NJR scientific committee. It was also supported by the NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol.

EL, MRW and AWB have received grant funds to investigate the outcome of implant bearings surface for total hip replacement (CeramTec GmbH), outside the submitted work. AJ has received consultancy fees from Freshfields Bruckhaus Deringer and has held advisory board positions (which involved receipt of fees) from Anthera Pharmaceuticals, INC, outside the submitted work. AWB and MRW have received grant funds to investigate the outcome of a design of primary total knee replacement (Stryker, Triathlon), outside the submitted work. AR reported receiving grants from the National Institute of Health Research (NIHR), Orthopaedic Research UK, and DePuy Synthes Limited outside the submitted work. MRW conducts teaching on courses sponsored by Heraeus and DePuy for which his institution receives market rate payments. All other authors declare no conflicts of interest. AJ, MW, AWB, were supported by the NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol.