Inequalities in provision of hip and knee replacement surgery for osteoarthritis by age, sex, and social deprivation in England between 2007-2017: A population-based cohort study of the National Joint Registry

BackgroundWhile the United Kingdom National Health Service aimed to reduce social inequalities in the provision of joint replacement, it is unclear whether these gaps have reduced. We describe secular trends in the provision of primary hip and knee replacement surgery between social deprivation groups. Methods and findingsWe used the National Joint Registry to identify all hip and knee replacements performed for osteoarthritis from 2007 to 2017 in England. The Index of Multiple Deprivation (IMD) 2015 was used to identify the relative level of deprivation of the patient living area. Multilevel negative binomial regression models were used to model the differences in rates of joint replacement. Choropleth maps of hip and knee replacement provision were produced to identify the geographical variation in provision by Clinical Commissioning Groups (CCGs).A total of 675,342 primary hip and 834,146 primary knee replacements were studied. The mean age was 70 years old (standard deviation: 9) with 60% and 56% of women undergoing hip and knee replacements, respectively. The overall rate of hip replacement increased from 27 to 36 per 10,000 person-years and knee replacement from 33 to 46. Inequalities of provision between the most (reference) and least affluent areas have remained constant for both joints (hip: rate ratio (RR) = 0.58, 95% confidence interval [0.56, 0.60] in 2007, RR = 0.59 [0.58, 0.61] in 2017; knee: RR = 0.82 [0.80, 0.85] in 2007, RR = 0.81 [0.80, 0.83] in 2017). For hip replacement, CCGs with the highest concentration of deprived areas had lower overall provision rates, and CCGs with very few deprived areas had higher provision rates. There was no clear pattern of provision inequalities between CCGs and deprivation concentration for knee replacement.Study limitations include the lack of publicly available information to explore these inequalities beyond age, sex, and geographical area. Information on clinical need for surgery or patient willingness to access care were unavailable. ConclusionsIn this study, we found that there were inequalities, which remained constant over time, especially in the provision of hip replacement, by degree of social deprivation. Providers of healthcare need to take action to reduce this unwarranted variation in provision of surgery. Author summary Why was this study done? Joint replacements are among the more frequent elective surgeries performed in developed settings.In England, inequalities in provision of joint replacement surgery were reported more than a decade ago, followed by a national effort to reduce these inequalities.In a context of increasingly strained National Health Service funding and hospital budgets, alongside prolonged efforts to increase surgical capacity, it is unclear what impact these have had on inequalities in provision of joint replacement for osteoarthritis. What did the researchers do and find? We conducted an analysis of the National Joint Registry using all primary hip and knee replacements for osteoarthritis performed from 2007 to 2017 in England, merged with the Office for National Statistics official population statistics, to investigate inequalities in provision of surgery according to deprivation by patient area of residence, age, sex, and trends in these inequalities over time.Using 675,342 primary hip and 834,146 primary knee replacements, we found that inequalities in provision of surgery between the most (reference) and least affluent areas have remained large (hip: rate ratio (RR) = 0.58, 95% confidence interval [0.56, 0.60] in 2007, RR = 0.59 [0.58, 0.61] in 2017; knee: RR = 0.82 [0.80, 0.85] in 2007, RR = 0.81 [0.80, 0.83] in 2017), despite the use of outsourcing of surgery to the private sector.For hip replacement, Clinical Commissioning Groups (CCGs) with the highest concentration of deprived areas had lower overall provision of surgery, and CCGs with very few deprived areas had higher surgical provision.There has been an overall improvement in the absolute numbers of hip and knee replacement operation being performed; there is now less geographical variation in rates of surgery. For publicly funded surgery, no socioeconomic inequalities were observed for knee replacements, with a smaller inequality observed for hip replacements, whereas for privately funded surgery, strong inequalities were observed for both joints. What do these findings mean? This study found that socioeconomic inequalities in provision of joint replacement surgery are still prevailing.Care providers should take action to address unwarranted variation in the provision of joint replacement surgery.

Automated summary

This study examined the provision of primary hip and knee replacement surgery in the United Kingdom, specifically focusing on social inequalities in access to these procedures. The findings indicate that there have been persistent socioeconomic disparities in the provision of joint replacement surgery over the past decade. The authors emphasize the need for healthcare providers to address and reduce these unwarranted variations in access.