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Unfair bias in access to joint replacement

Female, elderly and poor patients remain less likely to be given hip or knee replacements

Louise Prime

Thursday, 12 August 2010

Access to hip and knee replacement in England is unfairly biased against patients who are female, elderly, and in economically deprived areas, shows research on bmj.com.

Researchers from the UK and Canada conducted a cross-sectional study to investigate geographical and socio-demographic factors associated with greater or poorer access to joint replacement operations in England. They used three datasets to calculate expected need of total knee or hip replacement, and actual provision of the procedures: the Somerset and Avon Survey of Health (a small-area population based survey), the English Hospital Episode Statistics (HES) database and the English Longitudinal Study of Aging (ELSA).

Their results indicated clearly that need for joint replacement was not being met, and that under-provision varied between patient groups.

People aged 60-84 years were more than twice as likely to have had a replacement than people aged 50-59, despite equal need being seen in both groups. But the very elderly – 85 years and above – were less likely to have had the operations.

Access was also skewed towards men: they received 31% more knee replacements relative to need than women, and 8% more for hip replacements.

Living in a deprived area drastically cut people’s access to necessary hip and knee replacement surgery: those in deprived areas received 70% less provision relative to need, compared with those in the most affluent areas.

Living in an urban area meant people were more likely than those in rural areas to have their need of knee replacement met. But the effect was reversed for hip replacement – those living in villages or isolated areas had the most provision relative to need.

People living in non-white areas of England were more likely to receive a knee replacement than people residing in mostly white areas, but the ethnic mix of an area did not affect access to hip replacement.

The authors conclude: “Policy makers should examine factors at the patient or primary care level to understand the determinants of inequitable provision.” 

In an accompanying editorial, Professors Ann Bowling and Martin McKee say further analyses using both NHS and private sector data should be conducted to find out whether the health needs of the population are being met.

They ask: “So far, health needs assessment has been the responsibility of primary care trusts and strategic health authorities. Now that the Department of Health in England has signified its intent to move to general practice commissioning, who, if anyone, will have the skills or interest to take on this important role?”

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