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``Not Everyone Who Needs One Is Going to Get One'': The Influence of Medical Brokering on Patient Candidacy for Total Joint Arthroplasty

Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital and Department of Medicine, University of Toronto, Toronto, ON, hudakp{at}smh.toronto .on.ca

Pamela Grassau, MSW, PhD c

Ontario Breast Cancer Community Research Initiative, Psychosocial Behavioural Research Unit, Toronto, ON

Richard H. Glazier, MD, MPH, FRCPC

Family & Community Medicine and Public Health Sciences, University of Toronto, Toronto, ON

Gillian Hawker, MD, MSC, FRCPC

Medicine and Health Policy, Management and Evaluation, and Clinical Epidemiology and Health Care Research Program, University of Toronto, Toronto, ON

Hans Kreder, MD, MPH, FRCSC

Orthopaedic Surgery & Health Policy, Management & Evaluation, University of Toronto, Toronto, ON

Peter Coyte, PhD

Department of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON

Nizar Mahomed, MD, ScD

Department of Surgery, University of Toronto, Toronto, ON

James G. Wright, MD, MPH, FRCSC

Surgery, Public Health Sciences, and Health Policy, Management and Evaluations, University of Toronto, Toronto, ON

Background. Many patients in Ontario, despite being appropriate candidates for total joint arthroplasty (TJA), are not offered surgery. To understand this discrepancy, the authors sought to explore the process by which physicians determine patient candidacy for TJA. Methods. Six focus groups (2 each of orthopedic surgeons, of rheumatologists, and of family physicians) and subsequent in-depth interviews were conducted with 50 practicing clinicians in Ontario. Results. Health care system constraints, including extensive waiting lists, lack of homecare and postoperative support, and, for surgeons, access to operating rooms and resources, are perceived by physicians to routinely influence the ultimate choice of candidates for TJA. Medical brokering, defined as strategies used by physicians in a constrained health system to prioritize patients and to negotiate relationships with other physicians, was an important factor in determining candidacy for TJA. Because individual physicians and surgeons appear to use their own criteria for making these decisions, and because these criteria are modified from time to time in response to specific institutional and system conditions, brokering results in varied decisions about candidacy regardless of patient suitability. Conclusions. Lack of consensus on the necessary patient characteristics for TJA candidacy does not in and of itself account for the discrepancy between the number of patients who are suitable candidates for TJA and those who receive the procedure. Until the process by which health care system constraints affect and complicate the decision-making process around TJA candidacy is more fully explored, patients may not receive appropriate and timely access to this procedure.

Key Words: health care constraints • medical brokering • decision making • candidacy for orthopedic surgery • prioritizing • waiting lists.

This version was published on September 1, 2008

Medical Decision Making, Vol. 28, No. 5, 773-780 (2008)
DOI: 10.1177/0272989X08318468


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