Hostname: page-component-5d59c44645-kw98b Total loading time: 0 Render date: 2024-02-25T20:42:44.767Z Has data issue: false hasContentIssue false

Prioritization of patients on waiting lists for hip and knee replacement: Validation of a priority criteria tool

Published online by Cambridge University Press:  01 November 2004

Barbara Conner-Spady
University of Calgary Western Canada Waiting List Project
Angela Estey
Capital Health, Edmonton, Alberta
Gordon Arnett
Capital Health, Edmonton, Alberta
Kathleen Ness
Capital Health, Edmonton, Alberta
John McGurran
Western Canada Waiting List Project University of Toronto
Robert Bear
University of Alberta
Tom Noseworthy
University of Calgary Western Canada Waiting List Project Steering Committee of the Western Canada Waiting List Project
Members of the Steering Committee of the Western Canada Waiting List Project: Dr. Tom Noseworthy (Chair), Professor and Head, Community Health Sciences, University of Calgary, Calgary, Alberta; Dr. Carolyn De Coster, Senior Researcher, Manitoba Centre for Health Policy, Winnipeg, Manitoba; Ms. Lauren Donnelly, Executive Director, Acute and Emergency Services Branch, Saskatchewan Health, Regina, Saskatchewan; Ms. Patricia Hosang, Executive Director, Urban Regional Support Services, Manitoba Health, Winnipeg, Manitoba; Dr. Isra Levy, Director, Office of Public Health, Canadian Medical Association, Ottawa, Ontario; Ms. Diane Lugsdin, Manager, Acute Care and Technology Unit, Quality Care, Technology and Pharmaceuticals Division, Health Policy and Communications Branch, Health Canada, Ottawa, Ontario; Dr. Barry Maber, Physician, Vice President, Saskatoon Health Region, Saskatoon, Saskatchewan; Mr. John McGurran, Project Director, Western Canada Waiting List Project, and Lecturer, Department of Public Health Sciences, University of Toronto, Toronto, Ontario; Ms. Kathleen Ness, Director, Clinical Performance, Information, Research, Capital Health, Edmonton, Alberta; Mr. Darrell Thomson, Special Advisor to the Executive Director and Board, British Columbia Medical Association, Vancouver, British Columbia.


Objectives: This study tested the reliability and validity of the Western Canada Waiting List Project priority criteria score (PCS) for prioritizing patients waiting for hip and knee arthroplasty.

Methods: Sixteen orthopedic surgeons assessed 233 consecutive patients at consultation for hip or knee arthroplasty. Measures included the PCS, a visual analogue scale of urgency (VAS urgency), and maximum acceptable waiting time (MAWT). Patients completed a VAS urgency, an MAWT, the Western Ontario McMaster Osteoarthritis Index (WOMAC), and the EQ-5D. Using correlational analysis, convergent and discriminant validity was assessed between similar constructs in the priority criteria and WOMAC. Median MAWTs were determined for five levels of urgency based on PCS percentiles. Internal consistency reliability was assessed with Cronbach's alpha.

Results: The sample of 233 patients (62 percent female) ranged in age from 18 to 89 years (mean, 66.3 years). A total of 45 percent were booked for hip and 55 percent for knee arthroplasty. Correlations were strong between the PCS and surgeon VAS urgency (r=.79) and weaker between patient and surgeon measures of VAS urgency (r=.24) and MAWT (r=.44). Correlation coefficients between similar constructs in the priority criteria and WOMAC ranged from 0.24 to 0.32 and were higher than those measuring dissimilar constructs. For decreasing levels of urgency, the median MAWT ranged from 10 to 12 weeks for surgeons and 4 to 12 weeks for patients. Cronbach's alpha was 0.79.

Conclusions: Results support the validity of the PCS as a measure of surgeon-rated urgency. Patients might be ranked differently with different prioritization measures.

© 2004 Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


Alberta Health and Wellness. 2003. Hip and knee replacement surgery-volumes and waiting times. Available at:
Arnett G, Hadorn DC, Steering Committee of the Western Canada Waiting List. 2003 Developing priority criteria for hip and knee replacement: results from the Western Canada Waiting List Project. Can J Surg. 46: 290296.Google Scholar
Batterbury M. 1999. A priority scoring system for cataract surgery in Liverpool: Implementation not successful. Available at:
Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. 1988 Validation study of WOMAC: A health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 15: 18331840.Google Scholar
Bellan L, Mathen M. 2001 The Manitoba Cataract Waiting List Program. CMAJ. 164: 11771180.Google Scholar
Brazier JE, Harper R, Munro J, Walters SJ, Snaith ML. 1999 Generic and condition-specific outcome measures for people with osteoarthritis of the knee. Rheumatology (Oxford). 38: 870877.Google Scholar
British Columbia Ministry of Health. 2003. Surgical wait list registry. Available at:
Brooks R. 1996 EuroQol: The current state of play. Health Policy. 37: 5372.Google Scholar
Brownlow HC, Benjamin S, Andrew JG, Kay P. 2001 Disability and mental health of patients waiting for total hip replacement. Ann R Coll Surg Engl. 83: 128133.Google Scholar
Campbell DT, Fiske DW. 1959 Convergent and discriminant validation by the multitrait-multimethod matrix. Psychol Bull. 56: 81105.Google Scholar
Conner-Spady B, Arnett G, McGurran J, Noseworthy T, Steering Committee of the Western Canada Waiting List Project (WCWL). 2004: Prioritization of patients on scheduled wait lists: Validation of a scoring system for hip and knee arthroplasty. Can J Surg. 47: 3744.Google Scholar
Conner-Spady B, Voaklander DC, Suarez-Almazor M. 1999 Responsiveness of the EQ-5D compared with the WOMAC and SF-36 in patients with hip and knee replacements. In: Badia M, Herdman M, Roset M, eds. Discussion papers 16th plenary meeting of the EuroQol Group. Barcelona: Catalan Institute of Public Health: 113133.
Coyte PC, Wright JG, Hawker GA, et al. 1994 Waiting times for knee-replacement surgery in the United States and Ontario. N Engl J Med. 331: 10681071.Google Scholar
Dennett ER, Kipping RR, Parry BR, Windsor J. 1998 Priority access criteria for elective cholecystectomy: A comparison of three scoring methods. N Z Med J. 111: 231233.Google Scholar
Dennett ER, Parry BR. 1998 Generic surgical priority criteria scoring system: The clinical reality. N Z Med J. 111: 163166.Google Scholar
Derrett S, Devlin N, Hansen P, Herbison P. 2003 Prioritizing patients for elective surgery: A prospective study of clinical priority assessment criteria in New Zealand. Int J Technol Assess Health Care. 19: 91105.Google Scholar
Derrett S, Paul C, Herbison P, Williams H. 2002 Evaluation of explicit prioritisation for elective surgery: A prospective study. J Health Serv Res Policy. 7 (Suppl 1): 1422.Google Scholar
Derrett S, Paul C, Morris JM. 1999 Waiting for elective surgery: Effects on health-related quality of life. Int J Qual Health Care. 11: 4757.Google Scholar
Dolan P. 1997 Modeling valuations for EuroQol health states. Med Care. 35: 10951108.Google Scholar
Edwards RT. 1999 Points for pain: Waiting list priority scoring systems. BMJ. 318: 412414.Google Scholar
Edwards RT, Boland A, Wilkinson C, Cohen D, Williams J. 2003 Clinical and lay preferences for the explicit prioritisation of elective waiting lists: Survey evidence from Wales. Health Policy. 63: 229237.Google Scholar
Fortin PR, Penrod JR, Clarke AE, et al. 2002 Timing of total joint replacement affects clinical outcomes among patients with osteoarthritis of the hip or knee. Arthritis Rheum. 46: 33273330.Google Scholar
Gorsuch RL. 1983. Factor analysis. 2nd ed. Hillsdale: Lawrence Erlbaum;
Hadorn DC. 2000 Setting priorities for waiting lists: Defining our terms. Steering Committee of the Western Canada Waiting List Project. CMAJ. 163: 857860.Google Scholar
Hadorn DC, Holmes AC. 1997 The New Zealand priority criteria project. 1: Overview. BMJ. 314: 131134.Google Scholar
Hajat S, Fitzpatrick R, Morris R, et al. 2002 Does waiting for total hip replacement matter? Prospective cohort study. J Health Serv Res Policy. 7: 1925.Google Scholar
Halliwell T. 1998; How fair is cataract prioritization? N Z Med J. 405407.Google Scholar
Hanning M. 1996 Maximum waiting-time guarantee–an attempt to reduce waiting lists in Sweden. Health Policy. 36: 1735.Google Scholar
Hanning M, Spangberg UW. 2000 Maximum waiting time—a threat to clinical freedom? Implementation of a policy to reduce waiting times. Health Policy. 52: 1532.Google Scholar
Harry LE, Nolan JF, Elender F, Lewis JC. 2000 Who gets priority? Waiting list assessment using a scoring system. Ann R Coll Surg Engl. 82 (Suppl): 186188.Google Scholar
Hawker G, Wright J, Coyte P, et al. 1998 Health-related quality of life after knee replacement. J Bone Joint Surg Am. 80: 163173.Google Scholar
Ho E, Coyte PC, Bombardier C, Hawker G, Wright JG. 1994; Ontario patients' acceptance of waiting times for knee replacements. J Rheumatol. 21: 21012105.Google Scholar
Holtzman J, Saleh K, Kane R. 2002 Effect of baseline functional status and pain on outcomes of total hip arthroplasty. J Bone Joint Surg Am. 84: 19421948.Google Scholar
Institute for Clinical Evaluative Services (ICES). 2000. Information strategy: Urgency rating, waiting list management and patient outcomes monitoring for primary hip/knee joint replacement. Technical report. Ontario: ICES;
Jackson NW, Doogue MP, Elliott JM. 1999 Priority points and cardiac events while waiting for coronary bypass surgery. Heart. 81: 367373.Google Scholar
James M, St Leger S, Rowsell KV. 1996 Prioritising elective care: A cost utility analysis of orthopaedics in the north west of England. J Epidemiol Community Health. 50: 182189.Google Scholar
Jones CA, Voaklander DC, Johnston DW, Suarez-Almazor ME. 2000 Health related quality of life outcomes after total hip and knee arthroplasties in a community based population. J Rheumatol. 27: 17451752.Google Scholar
Kelly KD, Voaklander DC, Johnston DW, Newman SC, Suarez-Almazor ME. 2001 Change in pain and function while waiting for major joint arthroplasty. J Arthroplasty. 16: 351359.Google Scholar
Kili S, Wright I, Jones RS. 2003 Change in Harris hip score in patients on the waiting list for total hip replacement. Ann R Coll Surg Engl. 85: 269271.Google Scholar
Kipping R, Glenn R, McLeod H, Clark J. 2002. A review of priority scoring and slot systems for elective surgery. University of Birmingham, Health Services Management Centre;
Laupacis A, Bourne R, Rorabeck C, et al. 1993 The effect of elective total hip replacement on health-related quality of life. J Bone Joint Surg Am. 75: 16191626.Google Scholar
Lofvendahl S, Hellberg S, Hanning M. 2002 How was the referral sheet interpreted? Questionnaire on priority assessment of patients referred to orthopedic surgeons showed great differences between reviewers. Lakartidningen. 99: 19311939.Google Scholar
MacCormick AD, Collecutt WG, Parry BR. 2003 Prioritizing patients for elective surgery: A systematic review. ANZ J Surg. 73: 633642.Google Scholar
Mahon JL, Bourne RB, Rorabeck CH, et al. 2002 Health-related quality of life and mobility of patients awaiting elective total hip arthroplasty: A prospective study. CMAJ. 167: 11151121.Google Scholar
Mancuso CA, Ranawat CS, Esdaile JM, Johanson NA, Charlson ME. 1996 Indications for total hip and total knee arthroplasties. Results of orthopaedic surveys. J Arthroplasty. 11: 3446.Google Scholar
Mantyselka P, Kumpusalo E, Ahonen R, Takala J. 2001 Patients' versus general practitioners' assessments of pain intensity in primary care patients with non-cancer pain. Br J Gen Pract. 51: 995997.Google Scholar
Marquie L, Raufaste E, Lauque D, et al. 2003 Pain rating by patients and physicians: Evidence of systematic pain miscalibration. Pain. 102: 289296.Google Scholar
Martin DK, Giacomini M, Singer PA. 2002 Fairness, accountability for reasonableness, and the views of priority setting decision-makers. Health Policy. 61: 279290.Google Scholar
Maynard A. 1994 Prioritising health care—dreams and reality. In: Malek M, ed. Setting priorities in health care. Chichester: John Wiley and Sons: 118.
McDonald P, Shortt S, Sanmartin C, et al. 1998. Waiting lists and waiting times for health care in Canada: More management!! More money?? Ottawa: Health Canada;
Messick S. 1989 Validity. In: Linn R, ed. Educational measurement. New York: Macmillan Publishing Company: 13103.
Naylor CD, Williams JI. 1996 Primary hip and knee replacement surgery: Ontario criteria for case selection and surgical priority. Qual Health Care. 5: 2030.Google Scholar
Nekolaichuk CL, Bruera E, Spachynski K, et al. 1999 A comparison of patient and proxy symptom assessments in advanced cancer patients. Palliat Med. 13: 311323.Google Scholar
Nilsdotter AK, Lohmander LS. 2002 Age and waiting time as predictors of outcome after total hip replacement for osteoarthritis. Rheumatology (Oxford). 41: 12611267.Google Scholar
Noseworthy TW, McGurran JJ, Hadorn DC. 2003 Waiting for scheduled services in Canada: Development of priority-setting scoring systems. J Eval Clin Pract. 9: 2331.Google Scholar
Rissanen P, Aro S, Sintonen H, Slatis P, Paavolainen P. 1996 Quality of life and functional ability in hip and knee replacements: A prospective study. Qual Life Res. 5: 5664.Google Scholar
Streiner DL, Norman GR. 1995. Health measurement scales: A practical guide to their development and use. 2nd ed. Oxford: Oxford University Press;
Suarez-Almazor ME, Conner-Spady B. 2001 Rating of arthritis health states by patients, physicians, and the general public. Implications for cost-utility analyses. J Rheumatol. 28: 648656.Google Scholar
Suarez-Almazor ME, Conner-Spady B, Kendall CJ, Russell AS, Skeith K. 2001 Lack of congruence in the ratings of patients' health status by patients and their physicians. Med Decis Making. 21: 113121.Google Scholar
Sutherland JE, Wesley RM, Cole PM, et al. 1988 Differences and similarities between patient and physician perceptions of patient pain. Fam Med. 20: 343346.Google Scholar
Tierney WM, Fitzgerald JF, Heck DA, et al. 1994: Tricompartmental knee replacement. A comparison of orthopaedic surgeons' self reported performance rates with surgical indications, contraindications, and expected outcomes. Knee Replacement Patient Outcomes Research Team. Clin Orthop. 209217.Google Scholar
Walker M. 2001. Waiting your turn: Hospital waiting lists in Canada (11th ed.). Vancouver, BC: The Fraser Institute;
Williams A. 1985 Economics of coronary artery bypass grafting. Br Med J (Clin Res Ed). 291: 326329.Google Scholar
Williams JI, Llewellyn TH, Arshinoff R, Young N, Naylor CD. 1997 The burden of waiting for hip and knee replacements in Ontario. Ontario Hip and Knee Replacement Project Team. J Eval Clin Pract. 3: 5968.Google Scholar
Woolhead GM, Donovan JL, Chard JA, Dieppe PA. 2002 Who should have priority for a knee joint replacement? Rheumatology (Oxford). 41: 390394.Google Scholar
Wright JG, Coyte P, Hawker G, et al. 1995 Variation in orthopedic surgeons' perceptions of the indications for and outcomes of knee replacement. CMAJ. 152: 687697.Google Scholar