Chapter 6
Hospital Services for Arthritis

Deborah Shipton, Nizar Mohammed, Kinga David, Elizabeth Badley 

Introduction 

While most individuals with arthritis and related conditions are treated in an ambulatory care setting, some will require admission to a hospital and/or
surgical intervention (Figure 6-1). 

Figure 6-1 Hospital services for people with arthritis and related conditions

Hospital Care 

People with arthritis are admitted to hospital more frequently than individuals without arthritis^1-3 for either surgical or non-surgical reasons. Non-surgical admissions to hospital, referred to as medical admissions, may be required to manage the non-joint related consequences of arthritis, arthritis-related pain and disability, or the side effects of drugs used to treat arthritis, such as gastrointestinal complications. Data on long-term care facilities, which are often used for rehabilitation after surgery, were not available for this chapter. 

Surgical Interventions 

Orthopedic surgery is the most common type of surgical intervention for arthritis. It presents a viable alternative when attempts at non-surgical management have failed to prevent joint pain or damage. Nearly all surgical procedures discussed in this chapter are elective, or performed under non-emergency conditions. This chapter does not address additional surgical procedures that individuals with arthritis require as a result of other co-morbid conditions.

Arthritis-related orthopedic procedures 

Orthopedic interventions for joint disorders range from fusion of wrist joints to total replacement of the knee joint. A comprehensive list of over 100 arthritis-related orthopedic procedures has been categorized into the following three groups, based on the frequency of the procedures: 

Joint Replacement - Primary and Revision 

Replacement of the joint can improve function and reduce pain in individuals with advanced arthritis. The hip and knee joints are most commonly replaced, but shoulder, elbow and finger joints can also be replaced surgically. This category includes revisions to previously replaced joints. 

Knee Procedures (Excluding Knee Replacement) 

Knee procedures include all arthritis-relevant orthopedic procedures performed on the knee to reduce pain or restore function, excluding knee replacement. Many of the knee procedures are performed on individuals with early arthritis or knee injuries in order to prevent further damage and eventual disability. Knee procedures include both outpatient and inpatient procedures. The vast majority of outpatient surgeries consist of arthroscopic procedures, which, as the name implies, are performed arthroscopically or “as through a key hole”. Inpatient surgeries, or other knee procedures, usually involve open surgery. Although many knee procedures can be performed by either means, the arthroscopic approach has increased in favour because it has fewer complications, requires less rehabilitation time and can often be performed as an outpatient procedure. 

Non-knee Procedures 

Non-knee procedures include spinal surgery and other non-knee procedures. Spinal surgery procedures are used to treat arthritis-related degeneration of the spine. Other non-knee procedures include the remaining arthritis-related orthopedic procedures, such as fusion of various unstable joints (arthrodesis), removal of a wedge of bone to correct limb alignment (osteotomy), diagnostic arthroscopy, synovectomy and excision of joints other than the knee. Many of these procedures can be performed arthroscopically. 

Data sources 

Data for this chapter were obtained from the Canadian Institute for Health Information (CIHI). While complete information on medical admissions and inpatient surgical procedures was available from all provinces from 1994 onward, data on outpatient surgical procedures have not been consistently available at the national level. Therefore, it has been possible to use only data from selected provinces. The Canadian Joint Replacement Registry Report team at CIHI analyzed the data on hip and knee replacement surgery. 

Arthritis and Related Diagnoses 

For most provinces, up to 16 relevant medical conditions per patient are recorded. Only admissions or procedures involving individuals with at least one arthritis or related diagnosis were included in this chapter. (See list in Table 6A-1 in the Methodological Appendix at the end of the chapter.) 

Arthritis and Related Orthopedic Procedures 

Only arthritis-relevant orthopedic procedures were considered in this chapter (Table 6A-2 in Methodological Appendix), and these were grouped according to the frequency of their occurrence. 

Results 

Admissions 

Of the 2.3 million hospital admissions of people 15 years and older in Canada in 2000, there were 200,000 (9%) associated with arthritis or related conditions. Seven percent of 1.5 million medical admissions and 11% of the 800,000 surgical admissions included arthritis as one of the 16 diagnoses associated with admission. 

Between 1994 and 2000, the rate of medical and surgical admissions for both arthritis-related and non-arthritis-related admissions decreased. Non-arthritis-related admissions showed a greater decrease than arthritis-related admissions (20% versus 8% respectively) (Figure 6-2). This pattern likely reflects changes in the delivery of care over the last 10 years,⁴ as outpatient care has replaced inpatient care as a result of attempts to reduce costs. Improvements in pharmacological and surgical treatments for arthritis may also explain some of the decrease in hospitalization for its medical consequences. 

Figure 6-2 Age- and sex-standardized rate of hospital admissions, by diagnosis, Canada, 1994-2000

The rate of admissions among those with arthritis or related conditions increased with age, rising much more sharply in the oldest age group for medical admissions than for surgical admissions (Figure 6-3); the rate was slightly higher among women than men. 

The rate of medical admissions among people with arthritis and related conditions varied substantially by province in 2000 (Figure 6-4). Alberta had the highest rate and British Columbia the lowest. Although in all of Canada the rate of medical admissions decreased between 1994 and 2000, rates increased in New Brunswick, Quebec and Saskatchewan, and rates in the other provinces either remained stable or decreased. The rates of surgical admissions also varied among the provinces, although the pattern differed from that of medical admissions. 

Source: Canadian Institute for Health Information (CIHI)/Hospital Morbidly Database (HMDB)

Source: Canadian Institute for Health Information (CIHI)/Hospital Morbidly Database (HMDB)

Orthopedic Procedures 

Since 1994, the rate of selected orthopedic procedures for arthritis and related conditions has remained under 500 per 100,000 adult population in Canada. The static rate per capita of orthopedic procedures in the intervening years conceals a 13% increase in the absolute number of procedures performed, with increases in both inpatient and outpatient procedures (Figure 6-5). 

The number of inpatient hip and knee replacements increased markedly. Since this was partially offset by a decrease in the number of all other inpatient procedures, the total number of all inpatient procedures increased by only a modest 10%. The number of outpatient procedures also increased by just over 10%, which may be accounted for by the increase in less invasive arthroscopy for many procedures, such as excision. Use of arthroscopic surgery, where appropriate, rather than open surgery reduces not only the patient's recovery time but also the medical institution's costs associated with post-operative care. 

In 2000, the most frequent arthritis-relevant procedures in Canada were knee arthroscopy, followed by knee and hip replacements (Figure 6-6). 

Figure 6-5 Number of inpatient and outpatient arthritis-related orthopedic procedures in selected provinces*, Canada, 1994-2000

Hip and knee replacements 

Since 1994, both the number and rate of hip and knee replacements performed on individuals with arthritis and related conditions have shown a marked increase. The rate of knee replacements increased by 36% (from 47 to 65 per 100,000 population); the rate of hip replacements increased by 10% (from 43 to 47 per 100,000) (Figures 6-7 and 6-8). 

Figure 6-7 Number of total hip and knee replacements per 100,000 population, Canada, 1994-2000

Figure 6-8 Age-standardized rate of total hip or knee replacement per 100,000 population, by sex, Canada, 1994-2000

In 2000, the rate of arthritis-related hip and knee replacement procedures was higher among women than men, particularly for knee replacements. The rate of increase of these procedures among both sexes has been similar since 1994, however. 

The rate of hip and knee replacements in Canada increased with age in 2000, peaking in the 75-84 year age group (Figures 6-9 and 6-10). Because of the age structure of the Canadian population, adults aged between 65 and 74 years had the largest number of hip and knee replacements. 

Figure 6-9 Number and crude rate of total knee replacements per 100,000 population, by age, Canada, 2000

Figure 6-10 Number and crude rate of total hip replacements per 100,000 population, by age,
Canada, 2000

The rates of hip and knee replacements varied considerably by province in 1994 and 2000 (Table 6-1). Alberta and Saskatchewan consistently reported rates that were among the highest in Canada, and the Quebec and Newfoundland rates were among the lowest. The rates in Manitoba showed the most noticeable increase between the two years. 

The average length of hospital stay for hip replacements was slightly longer than for knee replacements, likely reflecting the more routine nature of knee replacements. The average length of hospital stay for women was higher than for men for both hip and knee replacements (Figure 6-11). Previous findings have shown that women are more disabled at the time of replacement and require more assistance with daily activities, largely because they are more likely to be living alone. These findings may explain the longer length of hospital stay for women as compared with men. 

Figure 6-11 Average length of stay for patients with arthritis or a related condition undergoing total hip or knee replacement, by sex, Canada, 2000

The average length of stay in hospital for a total hip or knee replacement varied considerably by province in 2000 (Figures 6-12 and 6-13). Provinces performing the higher rates of hip and knee replacements per capita tended to have the lower average lengths of stay. 

Figure 6-12 Average length of stay for patients with arthritis or a related condition undergoing total hip replacement surgery, by sex and province, Canada, 2000

Figure 6-13 Average length of stay for patients with arthritis or a related condition undergoing total knee replacement surgery, by sex and province, Canada, 2000

Other orthopedic procedures 

Replacement of other joints was less frequent than that of the hip or knee, probably reflecting the higher prevalence of hip and knee arthritis. Unlike hip and knee replacements, the rate of replacement of other joints was higher among men than women (Figure 6-14). The rate overall increased by more than 20% over time. 

The rate of replacement of joints other than the hip or knee increased with age, peaking in the 55-64 age group. Replacement of other joints was more common in men than in women under 65 years of age but more common in women over 74 years of age (Figure 6-15). 

Figure 6-15 Rates of other replacements per 100,000 population for selected provinces*, by age and sex, Canada, 1994-2000

Between 1994 and 2000, the vast majority of knee procedures, with the exclusion of knee replacements, were performed arthroscopically (Figure 6-16). The rate of arthroscopic procedures remained fairly stable, and the rate of the other knee procedures (inpatient procedures) decreased by one-half. 

Figure 6-16 Age- and sex-standardized rates of knee procedures (excluding total knee replacements) for selected provinces* per 100,000 population, Canada, 1994-2000

In 2000, the rate of arthroscopic knee procedures varied with age, peaking in the 55-64 year age group among women and in the 45-54 year age group among men (Figure 6-17). These procedures are often used as surgical management of early arthritis,⁵ explaining the high use of these procedures in the younger age groups relative to the other relevant procedures presented. Unlike joint replacements, the rates for arthroscopic knee procedures were greater among men with arthritis and related conditions than women, especially in the younger age groups. The difference between the sexes in the use of these procedures may reflect the greater exposure of males to injury from physically demanding jobs or sports, which is a risk factor for the development of osteoarthritis. 

Figure 6-17 Rate of knee arthroscopy per 100,000 population in selected provinces*, by age and sex, Canada, 2000

The rates of arthritis-related spine and other non-knee procedures were much lower than rates of replacement and arthroscopy procedures (Figure 6-18). Rates of spine and other non-knee procedures varied with age, with a general decline in the oldest age groups (Figure 6-19). In most age groups, women recorded higher rates of spine and other non- knee procedures than men. 

Figure 6-19 Rate of spine and other non-knee procedures per 100,000 population in selected provinces*, by age and sex, Canada, 2000

The rates of all procedures varied dramatically by province. Prince Edward Island, New Brunswick and Saskatchewan reported the highest rates of knee arthroscopy, and Saskatchewan reported the highest rate of other knee procedures. New Brunswick and Nova Scotia reported the highest rates of non-knee procedures, followed by Saskatchewan and Ontario (Table 6-2). 

Across the provinces, other knee procedures varied the most (coefficient of variation = 0.8), and non-knee procedures varied the least (coefficient of variation = 0.3). 

The data regarding all orthopedic procedures covered in this chapter reveal the dramatic variation among the provinces in 2000. No single province had consistently high or low rates across all procedures. The smaller provinces showed the largest deviation from national rates as a result of the small numbers of procedures in these jurisdictions. 

Discussion 

Between 1994 and 2000, the per capita rate of medical admissions associated with arthritis showed an overall decrease, although this was comparatively less than that of all other admissions. The decrease likely reflects the change in patterns of delivery of care over the last 10 years,⁴ which saw the increasing substitution of outpatient for inpatient care for cost containment reasons. In addition, improvements in pharmacological and surgical treatments for arthritis may also explain some of the decrease in hospitalization for its medical consequences. 

The number of arthritis-related orthopedic procedures per capita has remained remarkably static since 1994, despite increases in the national prevalence of arthritis (see Chapter 2), the main indication for these procedures.⁶ Nevertheless, the total number of both inpatient and outpatient procedures has increased since 1994. The number of inpatient procedures increased modestly (approximately 10%) as a result of a dramatic increase in the number of hip and knee replacements. The number of outpatient procedures increased by just over 10% and is likely the result of the increased use of the less invasive arthroscopy (key hole surgery) to perform many procedures. 

A number of new technologies are emerging in the surgical treatment of arthritis and related disorders. These include new materials technology for the bearing surfaces of hip and knee replacements (cross-linked polyethylene, ceramics and metal bearings). These new bearing surfaces should prolong the service life of joint replacements to beyond 15 years. Additional trends include minimally invasive techniques for knee and hip replacement surgery. In the near future, computer-assisted joint replacement surgery will allow surgeons to implant artificial joints with greater precision and accuracy. The emergence of these and other improved surgical tools for the treatment of arthritis will likely increase the demand for surgery. 

In the future, access to surgical procedures may be limited by the availability of resources, including surgeons, anaesthetists, nurses, and operating room space, dissemination of techniques and restrictions on procedure volumes by hospital administrations. Special initiatives aimed at expanding the use of hip and knee replacements in various provinces have had partial success in increasing availability. Nevertheless, long waiting times⁷ and unmet need⁸ stand as proof that the current level of access does not match demand. 

With the exception of hip and knee replacement, there is little consensus about the clinical criteria for the surgical procedures examined in this chapter.^9-11As a result, it is difficult to assess the appropriateness of either current rates or changes over time. This is particularly relevant for knee arthroscopy, given the particularly high rates in Canada. 

The length of waiting times for surgical procedures can provide an indication of excess demand. Several provincial and regional collaborations are developing methods to assist in the management of waiting lists for various types of surgery, although as yet waiting times for any of the orthopedic procedures are not tracked nationally. The Canadian Joint Replacement Registry team at CIHI is developing a pilot study for the collection of waiting times for hip and knee replacement surgery at the national level. 

Although hip and knee replacement procedures are slightly more commonly performed on women than men, this does not wholly reflect the greater need among women.⁸ The higher prevalence of arthritis among women is only partially reflected in the rates of orthopedic procedures. While the higher rates of joint injury requiring repair among younger men may partially explain this difference for some of the procedures (particularly knee arthroscopy), it does raise the question of gender equity in the use of these services. The higher rate of arthritis-associated medical admissions among women reflected the higher rate of arthritis. 

The use of all arthritis and related care increased markedly with age, mirroring the increase in the prevalence of arthritis with age. While the rate of medical admissions continued to climb, however, the rate of orthopedic procedures reached a plateau in the older age groups. 

Variation among the provinces in both orthopedic procedures and medical admissions was considerable, even after adjusting for differing age and sex compositions. Variations in the need for surgery are unlikely to account for the large disparity in rates. Many factors, such as province-specific health service provision and funding, manpower levels,¹² physician reimbursement methods,¹³ physician attitudes¹⁴ and expertise, as well as lack of guidelines for the appropriate use of surgical procedures all play a role in the large disparity in rates. 

Implications 

Despite an increase in the prevalence of arthritis in Canada, overall rates of orthopedic procedures have remained steady. This suggests that the system may be operating at capacity and may not be able to respond to increases in the number of people with arthritis. 

Although the rate of hip and knee replacements is increasing, the long waiting times for these procedures indicate that the capacity is insufficient to meet either current or future needs. 

The continued development of national and provincial registries related to hip and knee replacement would help ensure complete coverage. If appropriate in scope, such registries could enable tracking of waiting times, patient-based indicators of need, complications after surgery and failure rates of prostheses. 

The large provincial variations in rates of surgery for arthritis and related conditions, which are unlikely to be accounted for by differences in factors such as prevalence, suggest unequal access to orthopedic surgery across Canada. The causes of provincial variations and their impact at both the individual and population levels need to be determined. 

Currently, the published data on arthroscopic knee surgery for osteoarthritis are unclear on its effectiveness. More research is required in this area to properly define the appropriate indications for these procedures. 

The decline in rates of surgery at older ages and sex differences in surgery rates raise issues of inequities in access to care that need to be investigated.  

Linking hospitalization data with provincial physician billing data would facilitate better understanding of the processes of arthritis care and the outcomes of surgery. 

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