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Patient choice in elective care increased emergency readmissions

BMJ 2019; 365 doi: (Published 15 April 2019) Cite this as: BMJ 2019;365:l1793

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Re: Patient choice in elective care increased emergency readmissions

This article purports to suggest that an increase in patient choice has caused an increase in the rate of readmissions of patients following joint replacement surgery. The article is based on a paper given by a group of economists to a conference of economists. Unfortunately the article does not contain a link to any conference abstract, but it is possible to find the gist of what was said online. Overall the article is a fairly typical bad news story about orthopaedic surgery.

Choice was first introduced to the NHS for elective orthopaedic surgery by the Thatcher reforms of the early 1990s, not in 2006. Real choice has been available since the 1990s, particularly in large conurbations, but it is significantly constrained in areas with a limited number of providers and it is further constrained by the actions of CCG's and advice given by GPs. There is general inertia by patients, who are no more enthusiastic to change their hospital than change their electricity provider. There is therefore some type of market operating, but in reality only the more active patients are engaged in it, and not a lot has changed since 2006.

It would be quite possible that there has been a problem with quality, and a rise in complications causing readmission, due to tariff deflation. The NHS tariff for joint replacement surgery has been reduced far more drastically than other types of surgery, such as cardiac surgery. This is obviously a reflection of the fact that cardiac surgeons and cardiologists are far more important people than orthopaedic surgeons. I think that this simple explanation of budget cuts causing poor quality is likely to be incorrect. In our hospital we have certainly become more efficient due to a focus on issues such as theatre downtime and we have also made further reductions to length of stay, but there has been absolutely no compromise on quality, we have a very active programme of quality improvement.

It is quite possible that reducing lengths of stay down to 1 to 2 days for joint replacement surgery has resulted in a small increase in readmissions, however most of our patients benefit greatly from reductions in length of stay. Short stays tend to be popular with patients and their families, and there is no evidence that they are associated overall with increased complication rates.

Another factor which has changed in recent years is the approach to possibly infected wounds. A few years ago an infected wound might be treated with oral antibiotics as an outpatient but now a much more active approach is taken with investigation using ultrasound, wound washouts and IV antibiotics. This results in the readmission of a small percentage of patients, but it is an indicator of improving quality and safety, not a decline.

The economists would have done well to study the revision rates of total joint replacements over the past 10 years which show a relentless year-on-year improvement in revision rates. These improvements have occurred both as a result of changes in surgical technique but, probably more importantly, as a result of the efforts of our anaesthetic colleagues and as a result of preoperative optimisation by well organised multidisciplinary teams.

Competing interests: No competing interests

25 April 2019
Andrew M Thomas
Consultant Orthopaedic Surgeon
The Royal Orthopaedic Hospital, Birmingham
The Royal Orthopaedic Hospital, Birmingham