Total Joint Network improves access to surgery

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The wait is over for a solution to more accessible hip and knee replacements in Ontario. With an innovative approach to increase capacity, Total Joint Network (TJN), a Greater Toronto Area program, is now up and running. A partnership of 26 institutions across the GTA, the TJN will operate out of the Toronto Western Hospital and will work with its partner institutions to increase access to total joint replacement surgery (TJRs).

“We’re very excited to be taking this step toward more accessibility of total joint replacement (TJR),” said Dr. Nizar Mahomed, Director of Musculoskeletal Health and Arthritis Program, University Health Network, and TJN Program Chair. “The partnership’s intent is to deliver an efficient and effective solution that can be expanded to other regions within Ontario.” Based on the evaluated results of this project, planning for a GTA model of care could significantly impact on accessibility, utilization and coordination. Dr. Mahomed recognized an opportunity to improve patient access after he completed research two and a half years ago, which tested differences between home rehabilitation and inpatient rehabilitation post TJRs.

The goal of the TJN is to decrease wait times by increasing capacity. This will be achieved by first reducing the total length of patient stay in hospital and second by improving the integration of the systems across the continuum of care for TJRs. “The underlying principle that makes this program work is co-operation,” said Dr. John Flannery, Medical Director of Toronto Rehabilitation Institute’s Hillcrest Centre, which is one of the two founding hospitals involved in creating and developing the program. “We’ve brought 26 institutions together to make the patient experience from pre operative consultation to community reintegration more consistent.”

Depending on the condition of each patient prior to surgery, patient stay in acute care and inpatient rehabilitation will be shortened, with many patients able to bypass inpatient rehab altogether to receive home-based rehabilitation through Community Care Access Centres (CCAC). Patients will now be assessed for the type of treatment stream they need based on criteria such as available home support, co-morbidities, and walking ability prior to surgery. “Through the expedited home rehabilitation stream, clients will receive the appropriate care in the most appropriate setting, which now includes home care,” said Cathy Szabo, Executive Director of Etobicoke and York Community Care Access Centre. Based on the research led by Dr. Mahomed, it has been shown that despite concerns about early hospital discharge, there was no difference in functional outcomes and in patient satisfaction between the groups receiving home-based and inpatient rehabilitation.

An integral part of the proposed model is consistent patient education prior to surgery. “Education is a simple, yet critical intervention to making this model work,” said Dr. Flannery. “In particular it helps inform a patient about what to expect in the recovery process and gives patients the opportunity to make necessary changes to their home to be ready for their return.” This will serve as an opportunity for patients to obtain additional information, resolve confusion and ensure the patient is properly prepared for their respective care path.

Hip and knee replacements are among the most commonly performed surgical procedures in Ontario. Although the number of surgeries performed has increased, wait list times have increased dramatically. According to the Canadian Joint Replacement Registry (CJRR), led by the Canadian Institute for Health Information (CIHI) from 1993 to 2001, the median wait times for total knee replacement increased from 20 weeks to 29 weeks and from 16 to 20 weeks for primary total hip replacement. There is a general consensus that ideal wait times for this type of surgery should be within 12 weeks of the decision to proceed with surgery, or within 24 weeks at the outside.

The chief cause of growing wait lists is the continually increasing demand for this type of surgery. The aging population and advancing technology have been strong factors contributing to increased demand. The most common diagnosis group receiving total hip and knee replacement are those patients with degenerative osteoarthritis, an age-related disease. Furthermore, the decision to operate has been made easier through advancements in technology, which allow for TJRs to be less invasive and have longer lasting benefits.