The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 93, Issue 9

Scientific Articles | May 04, 2011

Provision of Orthopaedic Workforce and Implications for Access to Orthopaedic Services in Ontario

Elizabeth M. Badley, PhD¹; Mayilee Canizares, MSc¹; Nizar Mahomed, MD, ScD, FRCSC¹; Paula Veinot, MPH¹; Aileen M. Davis, PhD¹

¹ Arthritis Community Research and Evaluation Unit, Toronto Western Research Institute, Main Pavilion 10-316, 399 Bathurst Street, Toronto, ON M5T 2S8, Canada. E-mail address for E.M. Badley: ebadley@utoronto.ca

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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Ontario Ministry of Health and Long-Term Care. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Arthritis Community Research and Evaluation Unit at the Toronto Western Research Institute, Toronto, Ontario, Canada

J Bone Joint Surg Am, 2011 May 04;93(9):863-870. doi: 10.2106/JBJS.I.01782

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Abstract

Background:

The aging population and increasing obesity rates will increase the prevalence of musculoskeletal conditions. Reports of orthopaedic surgeon shortages raise concerns about the ability of the health-care system to meet current and future demand in orthopaedics. A survey of all orthopaedic surgeons in Ontario, Canada, was carried out in 2006 to (1) update provision estimates of orthopaedic surgeons; (2) examine practice characteristics and perceived barriers to service; and (3) relate geographic availability of surgeons to population utilization of office-based and surgical orthopaedic services.

Methods:

A two-part questionnaire was sent to all orthopaedic surgeons in Ontario in 2006. Provision data in hours per week and full-time equivalents and practice patterns were analyzed by health region. Population-based data on the use of orthopaedic services were obtained from health service administrative databases.

Results:

There were 396 practicing orthopaedic surgeons in Ontario in 2006, equivalent to 2.43 full-time equivalents per 100,000 population, a finding similar to surveys in 1997 and 2000. Most surgeons were male, with a mean age of forty-nine years, with mainly adult practices; 48% reported having a subspecialty. Provision varied across Ontario, with an average of 112 hours per week of direct clinical time per 100,000 population (50% in the office, 30% in the operating room, 20% working on call). Many surgeons also reported time for administration, teaching, and research. Most respondents reported barriers to timely surgery, notably a lack of resources (operating room time, anesthesia, nursing, and/or bed capacity). Low orthopaedic provision was associated with lower utilization of office-based and surgical services, after controlling for neighborhood income and type of residence (urban or rural).

Conclusions:

Shortages and geographic variation in the supply of surgeons mean that access to care continues to be a challenge in Ontario. In regions with fewer surgeons, residents are more likely to be deprived of office-based services, potentially affecting access to surgery and to orthopaedic expertise. In light of a potential shortage of surgeons, alternative methods of service provision may be needed to respond to the aging of the baby boomer population and an anticipated growth in the demand for surgery.

Figures in this Article

Introduction

The aging population and increasing obesity rates in Western nations are associated with a projected increase in the prevalence of musculoskeletal conditions such as osteoarthritis (the major reason for joint replacement surgery) and fragility fractures^1-6. Internationally, the rates of total joint replacement are increasing and there are concerns about variations in access and waiting times^7-11. Shortages of orthopaedic surgeons to deal with this demand have been noted in Canada, the United States, and other Western countries^2,12-17. Orthopaedic surgeons are also essential for trauma surgery, and they make substantial contributions to the nonoperative treatment of musculoskeletal conditions^18-21.

The orthopaedic workforce faces many human resource and workload challenges, including the increasing mean age of orthopaedic surgeons, with implications for renewal, and a chronic shortage of women in orthopaedics^15,17. There is no consensus on the optimum per capita provision of the orthopaedic workforce, with wide variations in provision internationally and regionally within a given country^17,22,23.

There are also large geographic variations in the rates of orthopaedic procedures^23-27. Studies have suggested that the regional variation observed may be induced in part by the supply of orthopaedic surgeons as well as practice pattern variations and physician preferences^25,26. As pointed out by Lurie and Weinstein²⁵, the question is not how many physicians there are, but what they do. The implications of the size, distribution, and characteristics of the orthopaedic workforce for the pattern of orthopaedic services and the provision of care to the population are not well understood. The objectives of the present research involving a defined population (Ontario, Canada) were (1) to examine the provision of orthopaedic surgeon services in 2006 and to update the findings from surveys of the orthopaedic workforce carried out in 1997 and 2000, (2) to examine geographic variation in the practice characteristics of orthopaedic surgeons (the amount of time that they devote to office and surgical care as well as working on call) and perceived barriers to service, and (3) to relate the geographic variation in the provision of orthopaedic services to population-based data on the utilization of orthopaedic office-based and surgical services.

Materials and Methods

Study Population

The present study integrates data from a survey of practicing orthopaedic surgeons in the province of Ontario, Canada, with data on service utilization for all residents of the province who accessed orthopaedic services in the fiscal year 2005 to 2006. Ontario is the most populous province in Canada, with a population of >12 million (40% of the total population of Canada), and is divided into fourteen health regions (called Local Health Integration Networks). The province has a publicly funded universal health-care system that covers all medically necessary physician visits, emergency room services, and procedures, including hospital inpatient and day-surgery services.

Orthopaedic Service Provision Data

All practicing orthopaedic surgeons in Ontario were identified from a directory listing of the College of Physicians and Surgeons of Ontario and were mailed an information letter in the spring of 2006 inviting them to complete a two-part self-administered postal questionnaire, similar to that used in previous surveys of this population^17,24,28. To be eligible, surgeons had to be in active practice in Ontario. Surgeons practicing primarily as Workers’ Compensation or medicolegal consultants were excluded as they would not be operating or contributing to clinic hours in a "treatment" capacity in the publicly funded health system. Postgraduate fellows were also excluded.

The questionnaire contained two parts. Part 1 included questions about the geographic location and length (in hours) of all office and operating room sessions as well as the amount of time working on call (time spent on patient care outside of surgery and office time). Part 2 included questions on practice patterns, including time spent on nonclinical activities (teaching, research, and administration), practice type (e.g., adult, pediatric), and the distribution of types of elective surgery (hip or knee replacement, other hip or knee surgery, foot or ankle surgery, upper extremity surgery, spine surgery, or other). Questions were asked on perceived barriers to providing timely care, with response options such as restricted operating room time, lack of anesthesia or nursing resources, limited bed capacity, the surgeon already working at full capacity, backlog in the clinic, and limited budget for implants. Demographic information included years in practice and anticipated retirement date.

As it was necessary to achieve a response rate close to 100% to obtain representative data on practice location (Part 1 of the questionnaire), an extensive reminder system was implemented, with a reminder letter being sent two weeks after the initial mailing and a telephone follow-up call being made two weeks after the reminder letter.

Orthopaedic Service Utilization Data

Information on age, sex, and diagnosis of Ontarians who accessed orthopaedic services in the fiscal year 2005 to 2006 (April 1 through March 31) was identified through health service utilization administrative databases. Patients’ encounters with orthopaedic surgeons in ambulatory settings (i.e., physicians’ offices, hospital outpatient departments) were identified through the Ontario Health Insurance Plan (OHIP) physician claims database²⁹. The Institute for Clinical Evaluative Sciences (ICES) Physician Database was used to identify physician specialty. This database was linked to the OHIP database to select consultations with orthopaedic surgeons. Data on age and sex were obtained by linking the physician claims database with the Ontario registered persons database. Hospital encounters were identified from the Canadian Institute for Health Information (CIHI) discharge abstract database, which contained a detailed record of all admissions, including surgical procedures, which were coded with use of the Canadian Classification of Health Interventions. We abstracted data on patients with an orthopaedic-related procedure code related to the musculoskeletal system¹⁸.

Measures

Orthopaedic service provision (office, surgery, and working on call) was calculated on the basis of the number of hours per week, taking into account surgeons who travel and provide service outside the health region of their main practice setting. The number of orthopaedic surgeon full-time equivalents was calculated on the basis of the reported number of hours of office, surgery, and working on-call time. One full-time equivalent was based on a standard forty-hour week of direct patient care (reported office, surgery, and working on-call time)²². Indicators for provision were calculated for the province as a whole and for each health region on the basis of postal code data provided by the surgeons for each practice setting. Surgeons spending >75% of their time seeing pediatric patients or on a particular type of surgery were identified as having a subspecialty of practice.

Orthopaedic service utilization was based on the patient's health region of residence and was measured on the basis of the number of people with at least one office-based encounter with an orthopaedic surgeon and the number of people undergoing orthopaedic procedures. An indicator of patient socioeconomic status based on neighborhood income was obtained from census data, and the type of residence (rural or urban) was obtained from the residential postal code classification used by Statistics Canada³⁰.

Data Analysis

Descriptive statistics were used to examine the practice patterns of orthopaedic surgeons in the province. The results of the 2006 survey were compared with those of the previous 2000 and 1997 surveys. To quantify the relationship between surgeon provision and the use of services at an individual level, a negative binomial regression model was used with an offset to incorporate region and age and sex-specific populations. Negative binomial regression was preferred as this distribution is more robust than Poisson regression when overdispersion is present³¹. Orthopaedic surgeon full-time equivalents per 100,000 population were categorized into quartiles for modeling. The unit of analysis was the ten-year age, sex, and region stratum. Two outcomes were used: the stratum-specific number of individuals with at least one office-based visit to an orthopaedic surgeon and the number of individuals undergoing orthopaedic procedures. All models included patient age, sex, neighborhood income, residence (rural or urban), type of surgery, and reason for the consultation and/or surgery¹⁸. All tests were performed at the 5% level of significance.

Ethics approval was given by the Institutional Research Boards of the University Health Network and Sunnybrook Health Sciences Centre for the orthopaedic surgeon survey and use of health services data, respectively.

Source of Funding

The present study was supported by a Health System Linked Research Unit Grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC) (Grant 04166), for salary support for Mayilee Canizares and Paula Veinot as well as for survey expenses. The opinions, results, and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by the Institute for Clinical Evaluative Sciences or the MOHLTC is intended or should be inferred.

Results

Survey Response

Questionnaires were mailed to 494 orthopaedic surgeons. Of these, 396 were practicing in Ontario in 2006, and ninety-eight were ineligible (thirty-two were retired, eighteen were practicing elsewhere, fourteen had Workers’ Compensation or medicolegal practices, and thirty-four were postgraduate fellows or were not in clinical practice). Three hundred and fifty-nine orthopaedic surgeons provided responses to questions in Part 1 about the location and nature of practice (a 91% response rate). Seventy-five percent (269) of the respondents answered questions on the characteristics of their practice, an overall response rate of 68% (269 of 396) for Part 2, although the response rate varied by question. There were no significant differences with respect to the mean number of office hours per week or surgery time or the region of the province between the orthopaedic surgeons who completed Part 1 only and those who responded to both Parts 1 and 2 (data not shown).

Service Provision and Practice Patterns

The findings on service provision and practice patterns relate to the 359 practicing orthopaedic surgeons in Ontario in 2006 who responded to Part 1 of the questionnaire. Overall, there were 2.86 surgeons per 100,000 population. This is a similar level of provision to that found in 1997 and 2000 surveys of Ontario orthopaedic surgeons (Table I). There was stability in the mean age of surgeons and the median number of years in practice, and there continued to be a minority of female surgeons (6.0%). The provision of service in terms of office and surgery hours per week was also similar. Of the surgeons in the 2006 survey, 335 (93.3%) operated and the remainder had exclusively office-based practices. The median expected year of retirement was 2019 (mean, 2020). While this question had a low response rate (34%), we believe that this was a reasonable estimate of potential retirement as tests for potential bias indicated there was no difference in the ages of the respondents and nonrespondents.

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TABLE I Time Trends in Orthopaedic Service Provision, 1997 to 2006: Arthritis Community Research and Evaluation Unit Surveys of Orthopaedic Surgeons in Ontario, Canada

				Provision per 100,000 Population
Year of Survey	Age*(yr)	No. of Years in Practice†	Female Sex	No. of Surgeons	No. of Office Hours/Week‡	No. of Surgery Hours/Week‡
2006§	49	15	6%	2.9	56.3	33.2
2000#	49	14	6%	2.9	60.0	32.9
1997#	45	13	6%	3.0	61.1	35.6

*The values are given as the mean.
†The values are given as the median.
‡In the 1997 and 2000 surveys, surgeons were asked to report the number of half days of office and surgery they work on average per week. For the present paper, half days were converted to hours per week, assuming that a half day is equal to four hours.
§Excluded surgeons who had predominantly medicolegal and Workers’ Compensation practices.
#Targeted to surgeons who managed patients with arthritis.

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TABLE I Time Trends in Orthopaedic Service Provision, 1997 to 2006: Arthritis Community Research and Evaluation Unit Surveys of Orthopaedic Surgeons in Ontario, Canada

				Provision per 100,000 Population
Year of Survey	Age*(yr)	No. of Years in Practice†	Female Sex	No. of Surgeons	No. of Office Hours/Week‡	No. of Surgery Hours/Week‡
2006§	49	15	6%	2.9	56.3	33.2
2000#	49	14	6%	2.9	60.0	32.9
1997#	45	13	6%	3.0	61.1	35.6

In addition to office and surgery time, the 2006 survey asked about time working on call. A table in the Appendix presents the number of orthopaedic surgeons as well as the per capita provision of surgeons per 100,000 population. The per capita provision is further broken down into office hours, surgery time, and time working on call. On the average, each orthopaedic surgeon in Ontario provided thirty-nine hours of direct clinical care per week. Taken together, this time represented 111.6 hours per week of direct clinical time per 100,000 population, with 50% of this time spent in seeing patients in the office (56.3 hours per week), 30% in surgery (33.2 hours per week), and 20% working on call (22.1 hours per week). On the basis of at least a forty-hour work week, the provision in 2006 was equivalent to 2.43 full-time equivalents per 100,000 population. Overall, one-third of the respondents reported working more than forty hours per week. The amount worked per week does not take into account the amount of time working in other duties, such as administration, teaching, research, reviewing tests, chart documentation, or reporting. However, this was explored in the second part of the questionnaire.

There was a more than threefold variation in the per capita provision of surgeons (full-time equivalents per population), which was also reflected in office and surgery hours and time working on call, across health regions. The highest provision of care was within regions with established teaching hospitals linked to universities that offer medical training (Fig. 1) (see Appendix). Sensitivity analyses taking into account the location of the thirty-seven nonresponding surgeons (9.3%) did not alter the overall provision of care. The amount contributed by the individual components of direct clinical care also varied according to health region (see Appendix).

Fig. 1

Map showing full-time equivalent (FTE) provision per 100,000 population of orthopaedic surgeons by health regions in Ontario, Canada, in 2006. (Reprinted with permission from the Arthritis Community Research & Evaluation Unit [ACREU], Toronto, Ontario, Canada.) LHIN = Local Health Integration Network.

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As might be expected, surgeons in health regions with teaching hospitals reported fewer working on-call hours and slightly shorter clinical hours than surgeons in regions without teaching hospitals. Findings from more detailed questions on practice patterns in Part 2 (n = 269) showed that 76%, 63%, and 42% of surgeons reported time spent on administration, teaching, and research, respectively, which was higher in regions with teaching hospitals (Table II).

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TABLE II Percentage of Surgeons with Nonclinical Duties, Average Weekly Workload, and Percentage of Surgeons with Subspecialty Orthopaedic Practices for Health Regions with and without Teaching Hospitals in Ontario, Canada, 2006

	Practice Location
	Regions with Teaching Hospitals	Other Regions	Ontario
Percentage of surgeons with nonclinical duties
Administration	79.5	70.2	75.6
Teaching	77.4	42.5	62.8
Research	54.9	24.1	42.0
No. of hours per week per surgeon*
Office hours (n = 359)	18.9	20.7	19.7
Surgery hours (n = 359)	11.9	11.3	11.6
Hours working on call (n = 359)	6.6	9.2	7.7
Administration (n = 269)	5.5	3.7	4.8
Teaching (n = 269)	5.5	1.4	3.8
Research (n = 269)	4.8	0.8	3.1
Percentage of surgeons with subspecialty practice (>75% of time)
Pediatrics (n = 265)	9.6	0.9	6.0
Total joint replacement (n = 242)	21.7	8.3	16.2
Other hip/knee (n = 242)	3.8	2.8	3.4
Upper extremity (n = 242)	10.2	6.5	8.7
Spine (n = 242)	7.6	3.7	6.0
Foot/ankle (n = 242)	6.4	0.9	4.2
Other (n = 242)	5.1	0.9	3.4
Any subspecialty (n = 265)	64.3	24.1	47.9

*Including office hours, surgery time, time working on call, and administrative, teaching, and research activities. The values are given as the average.

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	Practice Location
	Regions with Teaching Hospitals	Other Regions	Ontario
Percentage of surgeons with nonclinical duties
Administration	79.5	70.2	75.6
Teaching	77.4	42.5	62.8
Research	54.9	24.1	42.0
No. of hours per week per surgeon*
Office hours (n = 359)	18.9	20.7	19.7
Surgery hours (n = 359)	11.9	11.3	11.6
Hours working on call (n = 359)	6.6	9.2	7.7
Administration (n = 269)	5.5	3.7	4.8
Teaching (n = 269)	5.5	1.4	3.8
Research (n = 269)	4.8	0.8	3.1
Percentage of surgeons with subspecialty practice (>75% of time)
Pediatrics (n = 265)	9.6	0.9	6.0
Total joint replacement (n = 242)	21.7	8.3	16.2
Other hip/knee (n = 242)	3.8	2.8	3.4
Upper extremity (n = 242)	10.2	6.5	8.7
Spine (n = 242)	7.6	3.7	6.0
Foot/ankle (n = 242)	6.4	0.9	4.2
Other (n = 242)	5.1	0.9	3.4
Any subspecialty (n = 265)	64.3	24.1	47.9

*Including office hours, surgery time, time working on call, and administrative, teaching, and research activities. The values are given as the average.

Ninety percent of surgeons reported seeing mainly adult patients (that is, they spent at least 75% of their time with adults). Almost half of all surgeons reported a subspecialty practice (Table II); this proportion was higher in regions with teaching hospitals. Only 6% had a predominantly pediatric practice (3% had an exclusively pediatric practice), and 4% had a mixed practice (>25% with adults or children). The most frequently reported subspecialty practices were total joint replacement and upper extremity surgery. Only a minority spent more than one-quarter of their time seeing Workers’ Compensation patients (13.7%) or medicolegal patients (5.3%) (data not shown).

As waiting times for surgery have become an increasing concern for the public and policy-makers, we asked respondents about their perception of barriers to surgery. Overall, 98% of surgeons reported a mean of 3.5 barriers to timely orthopaedic surgery. The most frequently perceived barriers were lack of resources, particularly operating room time (indicated by 79.8% of surgeons), anesthesia (61.9%), nursing (60.3%), and bed capacity (53.2%). Additional barriers reported included reporting already working at full capacity (36.1%), a backlog in the clinic or office (28.2%), and restrictions on the implant budget (19.8%). "Other" barriers were mentioned by 10.3% of surgeons, with the most frequently identified barrier being a lack of orthopaedic surgeons. Only 1.6% of the surgeons indicated there were no barriers to providing timely care. There was some variation by health region in terms of the frequency of reported barriers, but there were no discernable differences between regions with and without teaching hospitals (data not shown).

Provision of Orthopaedic Services and Utilization

A table in the Appendix summarizes age and sex-adjusted rates of office visits to orthopaedic surgeons and orthopaedic surgery (inpatient and outpatient surgery) according to region. Overall, the person-visit rate for office-based care was almost four times higher than the rate of surgery. Regionally, there was a twofold difference in office visit rates and a two and a half-fold difference in surgical rates.

Quantification of the relationships between the provision of office and surgery hours and the utilization of orthopaedic services with use of regression, adjusting for demographic characteristics, showed significantly higher rates of office visits (rate ratio, 1.29; 95% confidence interval, 1.21 to 1.38) and surgery (rate ratio, 1.05; 95% confidence interval, 1.00 to 1.11) for the highest quartile versus the lowest quartile of full-time equivalents of provision. The relationship was even stronger for the highest quartile versus the lowest quartile of provision of office hours for both office visits (rate ratio, 1.61; 95% confidence interval, 1.44 to 1.80) and surgery (rate ratio, 1.39; 95% confidence interval, 1.24 to 1.56) (see Appendix). There was no association with surgery hours.

Discussion

This Ontario-based study showed no material change over the last decade in terms of the size and characteristics of the orthopaedic workforce. Surgeons continue to spend twice as much time in the office as in the operating room, and there is wide geographic variation in the per capita provision of care. A novel finding is the association of the amount of service provision with the rate of office visits, suggesting that lack of provision may be a barrier to access to care.

The similarity in findings to the 2000^17,27 and 1997²⁸ surveys is of concern, given the increasing rates of joint replacement and hip fracture surgery over time and the anticipated increase in demand for orthopaedic surgery due to an aging population^2,12-17,32. This finding, together with the fact that a substantial proportion of orthopaedic surgeons are close to retirement age, raises questions about the future supply of the orthopaedic workforce, particularly as surgeons under the age of fifty years work the longest hours in a week and as work time declines with age^22,33. Our findings for Ontario are similar to those for the United States (U.S.) in that only a minority of surgeons are women³⁴. The proportion of women in orthopaedic residency training programs traditionally has been low^35,36, and women are more likely to contribute fewer hours than men over the course of their careers^22,37. More generally, the fact that new surgeons entering the workforce are working shorter hours also may contribute to pressure on the future supply¹⁵, together with an increasing number of orthopaedic surgeons working below a full-time equivalent level due to resource restrictions³⁸ or leaving to work elsewhere³⁹. Ontario's overall supply of 2.86 orthopaedic surgeons (or 2.43 full-time equivalents) per 100,000 continues to fall short of the Canadian Orthopaedic Association estimate of need of 4.5 per 100,000³⁹. It is also somewhat lower than the estimate of 3.1 surgeons per 100,000 for Canada as a whole¹³. Our estimate is very much less than the demand-based requirement of five to seven full-time equivalents per 100,000 as recommended by Lee et al. in the United States⁴⁰. The Ontario estimate is comparable with the average of 2.96 surgeons per 100,000 for the United Kingdom (U.K.), which has a more similar health-care system to that of Canada⁴¹. However, this level of provision for the U.K. is less than the U.K. recommendations for optimum provision, which ranges from four to 6.7 per 100,000, similar to recommendations for the U.S., and it is less than that in many European countries^41,42. The impact of the supply of surgeons on meeting the needs of the population is difficult to gauge. However, it is unlikely that the need is less in Canada as the prevalence of arthritis is similar in the U.S. and Canada³⁷.

Meeting the needs of the population is also intimately associated with patterns of practice. A further constraint is the distribution of subspecialty practice. The overall proportion of surgeons in Ontario who reported a subspecialty practice is similar to that in the U.S.²². However, Canada has a higher proportion of surgeons who subspecialize in joint replacement surgery (16%) as compared with the U.S. (7%)¹⁶. In the U.S., a declining proportion of surgeons are subspecializing in joint replacement, which has been linked to reimbursement policies that have not kept pace with inflation¹⁶. This is becoming a concern in light of projected increases in need for this type of surgery^2,14. Both the U.S. and Canada have a low proportion of pediatric orthopaedic surgeons, which has been noted as an area of concern^33,43.

The discussion of the need for orthopaedic surgeons in the literature is mainly focused on resources available for surgery. However, the present survey indicates that, for those practicing in Ontario, only 30% of an orthopaedic surgeon's time is dedicated to surgery. This proportion is comparable to that for all Canadian orthopaedic surgeons⁴⁴ but is only half of the recommendation in the United States that 62% of an orthopaedic surgeon's time be dedicated to the operating room⁴⁰. The addition of an estimate of time spent working on call in the current study provides a more comprehensive picture of the orthopaedic workload. Time spent working on call represents about one-fifth of the total time spent in direct patient contact and is an important component of the commitment of the surgeon.

It is not known to what extent this relatively smaller proportion of time in the operating room is driven by hospital-based constraints such as operating room time and the availability of necessary supporting services such as nurses or anesthesiologists, or by external constraints such as budgets for prostheses. Insufficient operating room time was the most frequently perceived barrier to providing care in the present study. This barrier, as well as inadequate budgets for joint replacement implants and instruments, has been noted by others¹³. Comeau¹³ suggested that restricted operating room time means that fewer than half of Canada's practicing orthopaedic surgeons work at full surgical capacity. Recent initiatives in Ontario have demonstrated that, for joint replacement surgery, the amount of surgery carried out is sensitive to the availability of external resources⁸.

The ratio of almost 2:1 for office hours to surgery time points to the important role that orthopaedic surgeons play in providing nonoperative care. This ratio is similar to the finding in the U.S. for orthopaedic services in a capitated population⁸. Overall, the literature is relatively silent on the considerable role that orthopaedic surgeons play in the nonoperative treatment of musculoskeletal disorders^8,19,21.

In the present study, there was considerable variation in the reported provision and use of orthopaedic services across the health regions. Regional variation in the rates of orthopaedic services utilization has been noted elsewhere^23-27 and is of similar magnitude to that reported here. Although some studies have suggested that differential levels of surgeon supply might partially explain the observed geographic variation^8,25,45, it is not clear whether supply is directly linked to utilization. Certainly, regions with medical schools have a higher per capita provision of orthopaedic surgeons and an associated higher amount of office and surgery hours. However, these regions often act as regional referral centers for more complex surgical cases serving more than just the local regional population. As expected, surgeons in these regions were also more likely to devote time to other duties such as administration, teaching, and research. Other studies have suggested that differences in population demographics and socioeconomic status may contribute to differences in surgical rates⁴⁶ or waiting times⁴⁷.

To our knowledge, no previous study has related levels of orthopaedic provision of care with utilization of office as well as surgical services. The association between surgeon provision of care and the office visit rate was stronger than the association between surgeon provision of care and the surgical rate, particularly when the amount of office hours was considered. The lack of association at the individual level between surgery rates and surgery hours could be attributable to patients traveling to other health regions to receive care, particularly to teaching regions with specialist surgeons who provide services to a wide population. As a visit to a surgeon's office is the initial step on the road to surgery, these findings illustrate the importance of the presence of surgeons in ensuring access to surgical services. In Canada, referral from another physician, usually a primary care physician, is necessary for access to specialist care, and patients may also be referred for an opinion on musculoskeletal care. The waiting times for an initial consultation with an orthopaedic surgeon can be several months^8,47,48; however, most studies on waiting times have been related to total joint replacement surgery. Our findings highlight the importance of examining orthopaedic surgeon accessibility, taking into account not only the spatial distribution of surgeons but also the nature of the services that they provide and particularly their role in office-based care. Indeed, only a minority of patients seen by orthopaedic surgeons receive surgery⁴⁹.

A major strength of the present study is that we were able to examine data on the supply of orthopaedic services together with the utilization of office-based and hospital services in a large population with a publicly-funded health-care system, so our results are representative of the population as a whole. The high response rate to our survey of orthopaedic surgeons allowed us to accurately estimate the provision of orthopaedic services in the province.

The limitations of the analyses presented here are inherent to the use of self-reported data and administrative health-care utilization data. The 2006 survey was targeted to all orthopaedic surgeons, which precludes exact comparison with the 1997 and 2000 surveys, which were targeted to surgeons who managed patients who had arthritis. However, only a minority of surgeons have practices that do not include arthritis patients. The 2006 survey also excluded surgeons who had predominantly medicolegal and Workers’ Compensation practices; once again, this represents a minority of surgeons. Comparisons between countries are difficult as health-care systems differ, and there is little agreement on how to calculate full-time equivalents. Our calculation of full-time equivalents does not take into account reviews of laboratory tests and documentation in the chart, which are a part of U.S. estimates⁴⁰, or the additional hours that surgeons accrue annually on other activities, namely administration, teaching, and research. Our comparison of orthopaedic provision of care with use of services employed a provider-to-population ratio for each region. While these ratios are good for global comparisons across health regions, they do not take into account patients crossing health-region borders for care⁵⁰. We also were not able to incorporate the need for surgery or the appropriateness of the care provided. Finally, our study relates to Ontario, Canada, and it is unknown to what extent the findings might apply to other jurisdictions.

The present study underlines concerns with the future provision of orthopaedic care, which may not be adequate to respond to the aging of the baby boomer population and the anticipated growth in the demand for surgery. Surgeon shortages are compounded by variability in local availability. In regions where there are fewer orthopaedic services, residents are more likely to be deprived of office-based services, affecting both access to surgery and, more generally, access to orthopaedic expertise in the treatment of musculoskeletal conditions. There is a challenge to increase the capacity of surgeons to respond to the expected increased need for musculoskeletal care and increased demand for joint replacement and non-elective surgery. The availability of operating room and supporting services is crucial, particularly to enable surgeons to practice in under-serviced areas. In the short term, creative solutions will be needed, including adjustments in current practice patterns, such as the adoption of alternative models of care with greater involvement of primary care physicians or other health-care providers, such as physiotherapists, nurses, or physician assistants, to triage patients consulting for surgical options and to provide nonoperative care^7,51-59. The present study highlights the importance of taking into account how orthopaedic surgeons spend their time, particularly in the provision of office-based care for musculoskeletal disorders¹⁸. As the population continues to age, given shortages and geographic variation in supply of surgeons, access to care will continue to be a challenge.

Appendix

Tables presenting detailed orthopaedic surgeon demographic data, patient office visit data, surgery data, and associations between orthopaedic services provision and utilization are available with the online version of this article on our web site at jbjs.org.

Acknowledgements

Note: The authors thank the orthopaedic surgeons and the administrative staff who participated in the survey. They also acknowledge all of the staff at the Arthritis Community Research and Evaluation Unit (ACREU) who assisted with this project, in particular Hina Ansari, for assistance with the data analyses.

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Topics

aging ; obesity ; arthritis ; breast feeding ; demography ; health services ; health services accessibility ; teaching hospitals ; income ; musculoskeletal diseases

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Elizabeth M. Badley, Mayilee Canizares, Nizar Mahomed, Paula Veinot, Aileen M. Davis; Provision of Orthopaedic Workforce and Implications for Access to Orthopaedic Services in Ontario. The Journal of Bone & Joint Surgery. 2011 May;93(9):863-870.

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