Immigrated Canadians make up approximately 20% of the total population in Canada, and 30% of the population in Ontario. Despite universal health coverage and an equal prevalence of severe arthritis in immigrants relative to non-immigrants, the former may be underrepresented amongst arthroplasty recipients secondary to challenges navigating the healthcare system. The primary aim of this study was to determine if utilization of arthroplasty differs between immigrant populations and persons born in Canada. The secondary aim was to determine differences in outcomes following total hip and knee arthroplasty (THA and TKA, respectively).

This is a retrospective population-based cohort study using health administrative databases. All patients aged ≥18 in Ontario who underwent their first primary elective THA or TKA between 2002 and 2016 were identified. Immigration status for each patient was identified via linkage to the ‘Immigration, Refugee and Citizenship Canada’ database. Outcomes included all-cause and septic revision surgery within 12-months, dislocation (for THA) and total post-operative case cost and were compared between groups. Cochrane-Armitage Test for Trend was utilized to determine if the uptake of arthroplasty by immigrants changed over time.

There was a total of 186,528 TKA recipients and 116,472 THA recipients identified over the study period. Of these, 10,193 (5.5%) and 3,165 (2.7%) were immigrants, respectively. The largest proportion of immigrants were from the Asia and Pacific region for those undergoing TKA (54.0%) and Europe for THA recipients (53.4%). There was no difference in the rate of all-cause revision or septic revision at 12 months between groups undergoing TKA (p=0.864, p=0.585) or THA (p=0.527, p=0.397), respectively. There was also no difference in the rate of dislocations between immigrants and people born in Canada (p=0.765, respectively).

Despite having similar complication rates and costs, immigrants represent a significantly smaller proportion of joint replacement recipients than they represent in the general population in Ontario. These results suggest significant underutilization of surgical management for arthritis among Canada's immigrant populations. Initiatives to improve access to total joint arthroplasty are warranted.

The primary objective is to compare revision rates for lumbar disc replacement (LDR) and fusion at the same or adjacent levels in Ontario, Canada. The secondary objectives include acute complications during hospitalization and in 30 days, and length of hospital stay.

A population-based cohort study was conducted using health administrative databases including patients undergoing LDR or single level fusion between October 2005 to March 2018. Patients receiving LDR or fusion were identified using physician claims recorded in the Ontario Health Insurance Program database. Additional details of surgical procedure were obtained from the Canadian Institute for Health Information hospital discharge abstract. Primary outcome measured was presence of revision surgery in the lumbar spine defined as operation greater than 30 days from index procedure. Secondary outcomes were immediate/ acute complications within the first 30 days of index operation.

A total of 42,024 patients were included. Mean follow up in the LDR and fusion groups were 2943 and 2301 days, respectively. The rates of revision surgery at the same or adjacent levels were 4.7% in the LDR group and 11.1% in the fusion group (P=.003). Multivariate analysis identified risk factors for revision surgery as being female, hypertension, and lower surgeon volume. More patients in the fusion group had dural tears (p<.001), while the LDR group had more “other” complications (p=.037). The LDR group had a longer mean hospital stay (p=.018).

In this study population, the LDR group had lower rates of revision compared to the fusion group. Caution is needed in concluding its significance due to lack of clinical variables and possible differences in indications between LDR and posterior decompression and fusion.

Demand for total knee arthroplasty (TKA) is increasing as it remains the gold-standard treatment for end-stage osteoarthritis (OA) of the knee. While magnetic-resonance imaging (MRI) scans of the knee are not indicated for diagnosing knee OA, they are commonly ordered prior to the referral to an orthopaedic surgeon. The purpose of this study was to determine the proportion of patients who underwent an MRI in the two years prior to their primary TKA for OA. Secondary outcomes included determining patient and physician associations with increased MRI usage.

This is a population-based cohort study using billing codes in Ontario, Canada. All patients over 40 years-old who underwent a primary TKA between April 1, 2008 and March 31, 2017 were included. Statistical analyses were performed using SAS and included the Cochran-Armitage test for trend of MRI prior to surgery, and predictive multivariable regression model. Significance was set to p<0.05.

There were 172,689 eligible first-time TKA recipients, of which 34,140 (19.8%) received an MRI in the two years prior to their surgery. The majority of these (70.8%) were ordered by primary care physicians, followed by orthopaedic surgeons (22.5%). Patients who received an MRI were younger and had fewer comorbidities than patients who did not (p<0.001). MRI use prior to TKA increased from 15.9% in 2008 to 20.1% in 2017 (p<0.0001).

Despite MRIs rarely being indicated for the work-up of knee OA, nearly one in five patients have an MRI in the two years prior to their TKA. Reducing the use of this prior to TKA may help reduce wait-times for surgery.

The objective of this study was to quantify the burden of musculoskeletal disorders (MSDs) on the Ontario health care system. Specifically, we examined the magnitude and costs of MSD-associated ambulatory physician care and hospital service use, considering different physician types (e.g. primary care, rheumatologists, orthopaedic surgeons) and hospital settings (e.g. emergency department (ED), day surgery, inpatient hospitalizations).

Administrative health data were analyzed for fiscal year 2013/14 for adults aged 18+ years (N=10,841,302). Data sources included: Ontario Health Insurance Plan Claims History Database, which captures data on in- and out-patient physician services, Canadian Institute for Health Information (CIHI) Discharge Abstract Database, which records diagnoses and procedures associated with all inpatient hospitalizations, and CIHI National Ambulatory Care Reporting System, which captures data on all emergency department (ED) and day surgery encounters. Services associated with MSDs were identified using the single three digit International Classification of Diseases (ICD) version 9 diagnosis code provided on each physician service claim for outpatient physician visits and the “most responsible” ICD-10 diagnosis code recorded for hospitalizations, ED visits and day surgeries. Patient visit rates and numbers of patients and visits were tabulated according to care setting, patient age and sex, and physician specialty. Direct medical costs were estimated by care setting. Data were examined for all MSDs combined as well as specific diagnostic groupings, including a comprehensive list of both trauma and non-trauma related conditions.

Overall, 3.1 million adult Ontarians (28.5%) made 8 million outpatient physician visits associated with MSDs in 2013/14. These included 5.6 million primary care visits, nearly 15% of all adult primary care visits in the province. MSDs accounted for 560,000, 12.3%, of all adult ED visits. Patient visit rates to the ED for non-trauma spinal conditions were the highest of all MSDs at 1032 per 100,000 population, accounting for 23% of all MSD-related ED visits. Osteoarthritis had the highest rate of inpatient hospitalization of all MSDs at 340 per 100,000 population, accounting for 42% of all MSD-related admissions. Total costs for MSD-related care were $1.6 billion, with 12.6% of costs attributed to primary care, 9.2% to specialist care, 8.6% to ED care, and 61.2% of total costs associated with inpatient hospitalizations. Costs due to ‘arthritis and related conditions’ as a group accounted for 40.1% of total MSD costs ($966 million). Costs due to non-trauma related spinal conditions accounted for 10.5% ($168 million) of total MSD costs. All trauma-related conditions (spine and non-spine combined) were responsible for 39.4% ($627 million) of total MSD costs. MSD-related imaging costs for patients who made physician visits for MSDs were $169 million. Including these costs yields a total of $1.8 billion.

MSDs place a significant and costly burden on the health care system. As the population ages, it will be essential that health system planning takes into account the large and escalating demand for MSD care, both in terms of health human resources planning and the implementation of more clinically and cost effective models of care, to reduce both the individual and population burden.

Spine surgery is common and costly. Researchers and policy makers believe that utilization of spine surgery in the US is significantly higher than in other industrialized countries. Although within-country variation in spine surgery utilization is well studied, there has been little exploration of variation in spine surgery between countries.

We used population level administrative data from Ontario (years 2011–2015) and New York (2011–2014) to identify all adults who underwent inpatient spinal decompression or fusion surgery. We compared Ontario and New York with respect to patient demographics and the percentage of hospitals performing spine surgery. We compared rates of decompression and fusion surgery (procedures per-10,000 population per-year) in Ontario and New York for all procedures, emergent procedures alone, and elective procedures and after stratifying by patient age.

Patients in Ontario were older than patients in New York for decompression (mean age 58.8 vs. 51.3 years, P<.001) and fusion (58.1 vs. 54.9, P<.001). A smaller percentage of hospitals in Ontario performed decompression or fusion compared to New York (decompression, 26.1% in Ontario vs 54.9% in New York: fusion 15.2% vs 56.7%, both P<.001). Overall, utilization of spine surgery in Ontario was 6.6 procedures per-10,000 population per-year and in New York was 18 per-10,000 per-year (P<.001). Ontario-New York differences in utilization were small for emergent cases (2 per-10,000 in Ontario vs. 2.8 in New York, P<.001), but large for elective cases (4.6 vs 15.2, P<.001). In analyses stratified by surgical subtype, differences in utilization of decompression in New York and Ontario were relatively modest (2.4 vs 3.1, P<.001), while utilization of fusion was approximately 400% higher in New York than Ontario (15.7 vs 3.5, P<.001). Further analysis demonstrated that the New York-Ontario difference in utilization was substantially larger among younger patients and smaller for older patients. For example, utilization of spine procedures in New York was 340% greater than Ontario for patients less-than 50 years of age (11.7 vs 3.4), but only 25% greater in patients age 80 and above (10 vs 12.6).

After adjusting for patient demographics, hospital LOS and surgical urgency, differences in mortality in Ontario and New York were not significant for either decompression or fusion. In adjusted analyses differences in hospital LOS were slightly greater for decompression in Ontario, but similar for fusion and readmission rates in Ontario were significantly lower than in New York.

In conclusion, we found significantly lower utilization of spine surgery in Ontario when compared to New York. The difference in utilization was attributable to less elective fusion surgery, primarily in younger (i.e. non-Medicare) patients. These findings can serve inform broader spine surgery policy reforms in both jurisdictions.

Hospital Episode Statistics [HES] are often used by hospital managers and politicians as a reflection of departmental workload. The accuracy of these data is often questioned. We aimed to ascertain the reliability of this database for trauma admissions.

Between 2002 and 2003, all admissions were recorded by doctors using a separate departmental database. Data were collected during the daily trauma meetings and compared with the HES returns for the same period. 2496 patients were recorded in the trauma admissions database. Overall, 36.4% of the patients were either not recorded by the HES database or wrongly coded in terms of type of admissions or diagnosis.

HES data for all 2496 records was analysed by type of admissions and speciality.4.2% of trauma patients were incorrectly classified as elective or day cases. 2.9% of trauma patients admitted to hospital were not recorded in the HES data as orthopaedic admission.

The accuracy of HES diagnosis coding was tested on 300 records randomly selected by a statistical package. HES recorded the wrong diagnosis in 29.3% of cases. A significant number of trauma cases were not counted in the HES data. This may have significant implications for trauma funding.

HES data does not accurately record diagnosis and therefore can not be used as a research tool for specific injuries. Data recording practice should be changed to improve HES data accuracy.