Are Longer Waits Associated with Lower Satisfaction and Worse Recovery? A Retrospective Observational Study of Hip and Knee Replacement in England

Objectives

To examine whether longer waits for hip and knee replacement were associated with higher post-operative patient dissatisfaction and smaller patient-reported functional improvement, and whether worse post-operative satisfaction was associated with smaller functional improvement, in National Health Service (NHS) care in England.

Design

Retrospective observational study linking respondent-level Patient Reported Outcome Measures (PROMs) to provider-year Referral to Treatment (RTT) waiting times, with a supplementary comparison of the wait-dissatisfaction relationship in general practice.

Setting

NHS-funded hip and knee replacement in England, 2017, 2018, 2022 and 2023, excluding the pandemic-affected years 2019-2021.

Participants

107,700 hip and 122,756 knee replacement PROMs respondents, and all 42 Integrated Care Boards (168 ICB-year observations) for the general practice comparison.

Primary and Secondary Outcome Measures

Post-operative dissatisfaction (fair or poor on a five-point satisfaction scale) and Oxford Score improvement (post-operative minus pre-operative score). Secondary outcomes were EǪ-5D improvement and the full five-category satisfaction score.

Results

Each additional 30 days of average wait was associated with a 0.05 increase in the log-odds of post-operative dissatisfaction for hip (95% CI 0.03 to 0.08) and 0.04 for knee (0.03 to 0.06), and with smaller Oxford Score improvement (hip -0.26 points, -0.44 to -0.08; knee -0.11 points, -0.22 to -0.01). Mean Oxford Score improvement fell monotonically across satisfaction categories, from 26.11 points (hip) and 22.74 points (knee) among patients reporting excellent satisfaction to 2.62 and -0.01 points among those reporting poor satisfaction. In general practice, the wait-dissatisfaction association was close to zero but too imprecise to rule out an association of the size seen for hip and knee replacement.

Conclusions

In this focused surgical pathway, waiting times, post-operative satisfaction and patient-reported recovery were consistently associated, and satisfaction carried information about patient-reported recovery, not only about the experience of care. Performance frameworks that apply a common satisfaction measure across care settings should not assume it carries the same outcome content in each.

Strengths and Limitations of this Study

• Respondent-level national PROMs data observed waiting time, post-operative satisfaction and a validated functional outcome (Oxford Score) for the same 107,700 hip and 122,756 knee replacement patients.

• Two wait exposures, average wait and share of pathways completed after 18 weeks, were each adjusted for comorbidities and fixed effects, with ordered logit and EǪ-5D analyses as robustness checks.

• The wait exposure is a provider-year average across the whole trauma and orthopaedics treatment function, so it proxies rather than measures the procedure-specific wait.

• Case mix was adjusted only through 12 comorbidity flags; patient age and sex were not available in the PROMs extract.

• The design is observational, and because satisfaction is reported after recovery, the direction of the satisfaction-recovery association cannot be established.