HIQA has today published recommended referral and treatment thresholds for patients who may require pre-planned common hip and knee replacement procedures or key-hole surgery of the knee and shoulder.

The recommendations are aimed at identifying those people who stand to benefit most from each procedure assessed. Dr Máirín Ryan, Director of Health Technology Assessment in HIQA, said: “We are emphasising that the criteria are designed to distinguish between patients who would derive additional benefit from surgery over management by their family doctors. So patients who present with ‘red flag’ signs or symptoms, suggestive of, for example, a fractured hip, should continue to be referred for emergency or urgent assessment in secondary care.”

Substantial efficiency gains by the orthopaedic services include a decrease in average length of stay for hip replacement from 12.3 days in 2005 to 6.9 days in 2012. However, an aging population and increases in both obesity and chronic disease are placing increasing pressure on the Irish healthcare service, with demand for both outpatient appointments and scheduled surgical procedures continuing to exceed available capacity.

The recommendations state that where management in the community is indicated, this should be made available to patients at a time when they are most likely to derive benefit from it.

Dr Ryan continued: “Successful implementation of these thresholds will depend on timely access to primary care services, such as physiotherapy, for those who can be effectively managed in the primary care setting and who do not warrant referral to secondary care. Implementation of a specialist musculoskeletal programme to support general practitioners and community physiotherapists in the primary care setting may provide one solution to the need for increased access to timely and appropriate management in this setting. The recommendations also point out that implementation of a number of the thresholds will require additional resources to be directed towards physiotherapists working in the primary care setting.”

These are the latest in a series of reports making recommendations on scheduled procedures and they were developed following an extensive review of international best practice, consultation with an expert panel, and a public consultation by HIQA. The completed reports have been submitted to the HSE and to the Minister for Health.

These reports, and all the reports in this series of HTAs, are available to download from www.hiqa.ie

Further Information: 

Please contact: Marty Whelan, Head of Communications and Stakeholder Engagement
01 814 7480 / 086 2447 623 mwhelan@hiqa.ie

Notes to the Editor: 

HIQA is the statutory organisation in Ireland with a responsibility to carry out national health technology assessments (HTAs) and to develop guidelines for the conduct of HTAs across our healthcare system. 
The procedures which are included in Phase III of this series of HTAs include:

• Hip arthroplasty
• Knee arthroplasty
• Knee arthroscopy
• Shoulder arthroscopy.

Supporting documents include the ‘Background and Methods – Phase IV’ and ‘Ethical Analysis’ documents.
Osteoarthritis is the most common form of arthritis, and is the underlying reason for surgery in over 90% of people who have a hip or knee replacement.

Hip arthroplasty refers to any of those procedures in which an artificial hip or hip part (prosthesis) is implanted. These include total hip arthroplasty, hemiarthroplasty and hip resurfacing arthroplasty. There were 3,274 hip arthroplasties funded by the public health system in 2012 at an estimated cost of €37.3 million.

Knee arthroplasty is an umbrella term for a number of surgical options, namely total knee replacement – where the whole joint is replaced, and partial knee replacement – where only the most affected parts of the joint are replaced. There were 2,151 knee arthroplasties funded by the public health system in 2012 at an estimated cost of €25.6 million.

Knee and shoulder arthroscopy are operative techniques which facilitate visualisation of structures within the joint using a variety of fibre-optic telescopes, with images relayed to a screen. They may be performed in the day-case or in-patient setting and may be employed for diagnostic and/or treatment purposes.

At the end of April 2014, it was reported that there were 41,975 orthopaedic patients waiting for an outpatient appointment, 42.0% of whom were waiting longer than six months.