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Aust. J. Rural Health (2014) 22, 241–248
Original Research Prospective analysis of rural–urban differences in demographic patterns and outcomes following total joint replacement Michelle M. Dowsey, BHealthSci, PhD,1,2 Joshua Petterwood, BMedSci, MBBS(Hons),1,2 James P. Lisik, BBiomedSci,1,2 Jane Gunn, MBBS, FRACGP, DRANZCOG,3 and Peter F.M. Choong, MB BS, MD, FRACS, FAOrthA2 Departments of 1Orthopaedics and 2Surgery, St. Vincent’s Hospital Melbourne, and 3Primary Care Research, University of Melbourne, Melbourne, Victoria, Australia
Abstract Objective: Little is known about whether rural–urban differences exist in patients after hip and knee joint replacement surgery. We compared patient characteristics, pain and functional outcomes of rural and urban patients undergoing joint replacement surgery in a single high-volume metropolitan centre. Design: Prospective cohort study conducted in patients who underwent primary elective hip (THJR) or knee replacement (TKJR) between 1 January 2006 and 31 December 2009. Setting: A university-affiliated tertiary referral centre situated in the central metropolitan region of Melbourne, Australia. Participants: One thousand nine hundred fifty-five consecutive patients undergoing primary total joint replacement. Correspondence: Professor Peter F.M. Choong, Department of Surgery, St. Vincent’s Hospital Melbourne, The University of Melbourne, PO Box 2900, Fitzroy, Victoria, 3065, Australia. Email: [email protected] Declaration of conflict of interest: None of the authors have any financial or personal relationships with other people or organisations that could potentially and inappropriately influence their work and conclusions. 1. Dr Dowsey and Professor Choong receive research support on a multicentre study funded by DePuy. 2. Dr Dowsey and Professor Choong receive research support on a multicentre study funded by Allergan. 3. Professor Choong receives consultancy fees from DePuy for being part of education faculties. 4. Professor Choong is part of a surgeon design team for which he receives consultancy fees from DePuy for time spent. 5. Professor Choong receives royalties from Zimmer for tumour prosthesis design. Accepted for publication 13 February 2014. © 2014 National Rural Health Alliance Inc.
Main outcome measure: Pain and function were assessed preoperatively and 12 and 24 months postoperatively. The main independent variable was geographic location specifically comparing patients residing in rural/regional compared with urban communities. Results: A total of 2193 primary joint replacements were performed (981 THJR and 1212 TKJR) in 1955 patients. Rural patients presented at a younger age and with earlier radiographic disease than their urban counterparts. There was a higher rate of rheumatoid arthritis among rural patients presenting for TKJR. There was no difference in pain and function scores between groups at 12 and 24 months post-surgery. Conclusion: In our series of 1955 patients undergoing total hip and knee joint replacement surgery, rural patients presented at a younger age and an earlier stage of disease progression. At 24 months, rural patients had pain and functional outcomes as good as their urban counterparts. More research is required to determine which factors lead to the early presentation of rural patients. KEY WORDS: health outcome, pain and function, rural health, total hip replacement, total knee replacement.
Introduction In Australia, reports of poorer health status and generally worse health outcomes have led to the development of a number of rural health-specific policies and programs.1–4 However, the exact relationship between rurality and health outcomes remains unclear. Rural– urban differences for individual conditions are not uniform, and indeed, many conditions have been shown to be less prevalent and/or associated with doi: 10.1111/ajr.12100
242
What is already known on this subject: • Rural–urban differences for individual conditions are not uniform and many conditions have been shown to be either less prevalent or associated with improved outcomes in rural areas. • A number of studies have reported that people living in rural locations are more likely to undergo total joint replacement. This is despite a disparity in access to primary care physicians and specialists between people living in rural and urban locations. • Despite higher surgical utilisation rates, any urban–rural difference in outcome following total joint replacement surgery has not been examined in the literature.
M. M. DOWSEY ET AL.
What this study adds: • This prospective study suggests that patients presenting for total joint replacement from rural areas are more likely to present younger and with earlier stages of disease progression than patients from metropolitan regions. • Pain and functional outcomes at 12 and 24 months postoperatively are as good in rural patients as in their urban counterparts. • More research is required to ascertain why rural patients present earlier and to determine the need for health policy directed at increasing delivery of early non-operative measures for rural patients with arthritis.
Data collection improved outcomes in rural areas.5 A number of studies have reported that people living in rural locations are more likely to undergo total joint replacement (TJR). This is despite a disparity in access to primary care physicians and specialists between people living in rural and urban locations.6,7 Despite higher surgical utilisation rates, to our knowledge, any urban–rural difference in outcome following TJR surgery has not been examined. It is an important measure of national health care that health practitioners, hospital networks and governments are able to provide joint replacement surgery with excellent outcomes across both urban and rural populations. The development of rural health policy requires information on the factors responsible for any urban–rural health differential. The first step in this process is elucidating the existence and extent of any differences. We aimed to examine and compare patient characteristics and functional outcomes between rural and urban patients undergoing TJR in a single high-volume metropolitan centre.
Patients and methods Setting and patients This study was conducted in a university-affiliated tertiary referral centre situated in the central metropolitan region of Melbourne, Australia. All patients who underwent primary elective hip (THJR) or knee replacement (TKJR) between 1 January 2006 and 31 December 2009 were eligible for enrolment into the study.
Data on all TJRs were prospectively collected and recorded on the hospital joint replacement registry approved by the Human Research Ethics Committee of St. Vincent’s Hospital Melbourne. Patients attended a multidisciplinary pre-admission clinic prior to surgery, wherein ‘baseline’ preoperative data were collected according to a standardised protocol. This included patient demographics: age, sex, body mass index (BMI), socioeconomic status,8 age adjusted Charlson co-morbidity index,9 aetiology and radiographic arthritis severity according to the Kellgren-Lawrence grade.10 Patient follow up captured an extensive range of clinical outcomes. Health-related questionnaires are routinely administered to patients pre- and annually post-surgery including the International Knee Society Score (IKSS),11 the Harris Hip Score (HHS)12 and the Short-Form Health Survey (SF-12).13
Surgery Procedures were performed by a team of 14 surgeons using cemented and cementless implants. Individual surgeons did not alter their manufacturer or implant types during the study time frame.
Main independent variable The main independent variable was geographic location of patients residing in regional compared with metropolitan communities. Individual patient postcodes were matched to Australian Institute of Health and Welfare’s ‘Accessibility/Remoteness Index of Australia (ARIA+) classification’.14 ARIA is a geographic accessibility index that aims to reflect the ease or difficulty people face © 2014 National Rural Health Alliance Inc.
243
RURAL-URBAN DIFFERENCES IN JOINT REPLACEMENT
accessing services in non-metropolitan Australia. ARIA measures remoteness in terms of access along the road network from over 11 000 localities to five categories of service centres. These categories are major city, inner regional, outer regional, remote, very remote and migratory. Areas that are more remote have less access to service centres; areas that are less remote have greater access to service centres. In this study, we compared major city with inner and outer regional (rural) patients as there were no remote or migratory cases in our cohort.
Outcome variables The main outcome variables were pain and function at baseline and at 12 and 24 months following TJR which was assessed using subcomponents of the IKSS11 and HHS,12 with a lower score indicating greater pain or functional limitation.
Covariates Covariates included those routinely collected above, including baseline general health as measured by the SF-12.13 Radiographic arthritis severity was dichotomised into ‘end-stage’ for those with a K-L grade of 4 for comparison with those with ‘less severe’ arthritis as determined by a K-L grade
Aust. J. Rural Health (2014) 22, 241–248
Original Research Prospective analysis of rural–urban differences in demographic patterns and outcomes following total joint replacement Michelle M. Dowsey, BHealthSci, PhD,1,2 Joshua Petterwood, BMedSci, MBBS(Hons),1,2 James P. Lisik, BBiomedSci,1,2 Jane Gunn, MBBS, FRACGP, DRANZCOG,3 and Peter F.M. Choong, MB BS, MD, FRACS, FAOrthA2 Departments of 1Orthopaedics and 2Surgery, St. Vincent’s Hospital Melbourne, and 3Primary Care Research, University of Melbourne, Melbourne, Victoria, Australia
Abstract Objective: Little is known about whether rural–urban differences exist in patients after hip and knee joint replacement surgery. We compared patient characteristics, pain and functional outcomes of rural and urban patients undergoing joint replacement surgery in a single high-volume metropolitan centre. Design: Prospective cohort study conducted in patients who underwent primary elective hip (THJR) or knee replacement (TKJR) between 1 January 2006 and 31 December 2009. Setting: A university-affiliated tertiary referral centre situated in the central metropolitan region of Melbourne, Australia. Participants: One thousand nine hundred fifty-five consecutive patients undergoing primary total joint replacement. Correspondence: Professor Peter F.M. Choong, Department of Surgery, St. Vincent’s Hospital Melbourne, The University of Melbourne, PO Box 2900, Fitzroy, Victoria, 3065, Australia. Email: [email protected] Declaration of conflict of interest: None of the authors have any financial or personal relationships with other people or organisations that could potentially and inappropriately influence their work and conclusions. 1. Dr Dowsey and Professor Choong receive research support on a multicentre study funded by DePuy. 2. Dr Dowsey and Professor Choong receive research support on a multicentre study funded by Allergan. 3. Professor Choong receives consultancy fees from DePuy for being part of education faculties. 4. Professor Choong is part of a surgeon design team for which he receives consultancy fees from DePuy for time spent. 5. Professor Choong receives royalties from Zimmer for tumour prosthesis design. Accepted for publication 13 February 2014. © 2014 National Rural Health Alliance Inc.
Main outcome measure: Pain and function were assessed preoperatively and 12 and 24 months postoperatively. The main independent variable was geographic location specifically comparing patients residing in rural/regional compared with urban communities. Results: A total of 2193 primary joint replacements were performed (981 THJR and 1212 TKJR) in 1955 patients. Rural patients presented at a younger age and with earlier radiographic disease than their urban counterparts. There was a higher rate of rheumatoid arthritis among rural patients presenting for TKJR. There was no difference in pain and function scores between groups at 12 and 24 months post-surgery. Conclusion: In our series of 1955 patients undergoing total hip and knee joint replacement surgery, rural patients presented at a younger age and an earlier stage of disease progression. At 24 months, rural patients had pain and functional outcomes as good as their urban counterparts. More research is required to determine which factors lead to the early presentation of rural patients. KEY WORDS: health outcome, pain and function, rural health, total hip replacement, total knee replacement.
Introduction In Australia, reports of poorer health status and generally worse health outcomes have led to the development of a number of rural health-specific policies and programs.1–4 However, the exact relationship between rurality and health outcomes remains unclear. Rural– urban differences for individual conditions are not uniform, and indeed, many conditions have been shown to be less prevalent and/or associated with doi: 10.1111/ajr.12100
242
What is already known on this subject: • Rural–urban differences for individual conditions are not uniform and many conditions have been shown to be either less prevalent or associated with improved outcomes in rural areas. • A number of studies have reported that people living in rural locations are more likely to undergo total joint replacement. This is despite a disparity in access to primary care physicians and specialists between people living in rural and urban locations. • Despite higher surgical utilisation rates, any urban–rural difference in outcome following total joint replacement surgery has not been examined in the literature.
M. M. DOWSEY ET AL.
What this study adds: • This prospective study suggests that patients presenting for total joint replacement from rural areas are more likely to present younger and with earlier stages of disease progression than patients from metropolitan regions. • Pain and functional outcomes at 12 and 24 months postoperatively are as good in rural patients as in their urban counterparts. • More research is required to ascertain why rural patients present earlier and to determine the need for health policy directed at increasing delivery of early non-operative measures for rural patients with arthritis.
Data collection improved outcomes in rural areas.5 A number of studies have reported that people living in rural locations are more likely to undergo total joint replacement (TJR). This is despite a disparity in access to primary care physicians and specialists between people living in rural and urban locations.6,7 Despite higher surgical utilisation rates, to our knowledge, any urban–rural difference in outcome following TJR surgery has not been examined. It is an important measure of national health care that health practitioners, hospital networks and governments are able to provide joint replacement surgery with excellent outcomes across both urban and rural populations. The development of rural health policy requires information on the factors responsible for any urban–rural health differential. The first step in this process is elucidating the existence and extent of any differences. We aimed to examine and compare patient characteristics and functional outcomes between rural and urban patients undergoing TJR in a single high-volume metropolitan centre.
Patients and methods Setting and patients This study was conducted in a university-affiliated tertiary referral centre situated in the central metropolitan region of Melbourne, Australia. All patients who underwent primary elective hip (THJR) or knee replacement (TKJR) between 1 January 2006 and 31 December 2009 were eligible for enrolment into the study.
Data on all TJRs were prospectively collected and recorded on the hospital joint replacement registry approved by the Human Research Ethics Committee of St. Vincent’s Hospital Melbourne. Patients attended a multidisciplinary pre-admission clinic prior to surgery, wherein ‘baseline’ preoperative data were collected according to a standardised protocol. This included patient demographics: age, sex, body mass index (BMI), socioeconomic status,8 age adjusted Charlson co-morbidity index,9 aetiology and radiographic arthritis severity according to the Kellgren-Lawrence grade.10 Patient follow up captured an extensive range of clinical outcomes. Health-related questionnaires are routinely administered to patients pre- and annually post-surgery including the International Knee Society Score (IKSS),11 the Harris Hip Score (HHS)12 and the Short-Form Health Survey (SF-12).13
Surgery Procedures were performed by a team of 14 surgeons using cemented and cementless implants. Individual surgeons did not alter their manufacturer or implant types during the study time frame.
Main independent variable The main independent variable was geographic location of patients residing in regional compared with metropolitan communities. Individual patient postcodes were matched to Australian Institute of Health and Welfare’s ‘Accessibility/Remoteness Index of Australia (ARIA+) classification’.14 ARIA is a geographic accessibility index that aims to reflect the ease or difficulty people face © 2014 National Rural Health Alliance Inc.
243
RURAL-URBAN DIFFERENCES IN JOINT REPLACEMENT
accessing services in non-metropolitan Australia. ARIA measures remoteness in terms of access along the road network from over 11 000 localities to five categories of service centres. These categories are major city, inner regional, outer regional, remote, very remote and migratory. Areas that are more remote have less access to service centres; areas that are less remote have greater access to service centres. In this study, we compared major city with inner and outer regional (rural) patients as there were no remote or migratory cases in our cohort.
Outcome variables The main outcome variables were pain and function at baseline and at 12 and 24 months following TJR which was assessed using subcomponents of the IKSS11 and HHS,12 with a lower score indicating greater pain or functional limitation.
Covariates Covariates included those routinely collected above, including baseline general health as measured by the SF-12.13 Radiographic arthritis severity was dichotomised into ‘end-stage’ for those with a K-L grade of 4 for comparison with those with ‘less severe’ arthritis as determined by a K-L grade
