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1.  The pathway to orthopaedic surgery: a population study of the role of access to primary care and availability of orthopaedic services in Ontario, Canada 
BMJ Open  2014;4(7):e004472.
Objective
To examine the impact of access to primary care physicians (PCPs), geographic availability of orthopaedic surgeons, socioeconomic status (SES), proportion of older population (≥65 years) and proportion of rural population on orthopaedic surgeon office visits and orthopaedic surgery.
Design
Population multilevel study.
Setting
Ontario, Canada.
Participants
Ontario residents 18 years or older who had visits to orthopaedic surgeons or an orthopaedic surgery for musculoskeletal disorders in 2007/2008.
Primary and secondary outcomes
Office visits to orthopaedic surgeons and orthopaedic surgery.
Results
Access to PCPs and the index of geographic availability of orthopaedic surgeons, but not SES, were significantly associated with orthopaedic surgeon office visits. There was a significant interaction between access to PCPs and orthopaedic surgeon geographic availability for the rate of office visits, with access to PCPs being more important in areas of low geographic availability of orthopaedic surgeons. After controlling for office visits with orthopaedic surgeons, the index of geographic availability of orthopaedic surgeons was no longer significantly associated with orthopaedic surgery.
Conclusions
The findings suggest that, particularly, in areas with low access to PCPs or with fewer available orthopaedic surgeons, residents are less likely to have orthopaedic surgeon office visits and in turn are less likely to receive surgery. Efforts to address adequate access to orthopaedic surgery should also include improving and facilitating access to PCPs for referral, particularly in geographic areas with low orthopaedic surgeon availability.
doi:10.1136/bmjopen-2013-004472
PMCID: PMC4120425  PMID: 25082417
Primary Care
2.  Surgery or Consultation: A Population-Based Cohort Study of Use of Orthopaedic Surgeon Services 
PLoS ONE  2013;8(6):e65560.
Background
This population-based cohort study has the objective to understand the sociodemographic characteristics and health conditions of patients who do not receive surgery within 18 months following an ambulatory visit to an orthopaedic surgeon.
Methods
Administrative healthcare databases in Ontario, Canada were linked to identify all patients making an initial ambulatory visit to orthopaedic surgeons between October 1st, 2004 and September 30th, 2005. Logistic regression was used to examine predictors of not receiving surgery within 18 months.
Results
Of the 477,945 patients in the cohort 49% visited orthopaedic surgeons for injury, and 24% for arthritis. Overall, 79.3% did not receive surgery within 18 months of the initial visit, which varied somewhat by diagnosis at first visit (84.5% for injury and 73.0% for arthritis) with highest proportions in the 0–24 and 25–44 age groups. The distribution by income quintile of patients visiting was skewed towards higher incomes. Regression analysis for each diagnostic group showed that younger patients were significantly more likely to be non-surgical than those aged 65+ years (age 0–24: OR 3.45 95%CI 3.33–3.57; age 25–44: OR 1.30 95%CI 1.27–1.33). The odds of not getting surgery were significantly higher for women than men for injury and other conditions; the opposite was true for arthritis and bone conditions.
Conclusion
A substantial proportion of referrals were for expert diagnosis or advice on management and treatment. The findings also suggest socioeconomic inequalities in access to orthopaedic care. Further research is needed to investigate whether the high caseload of non-surgical cases affects waiting times to see a surgeon. This paper contributes to the development of evidence-based strategies to streamline access to surgery, and to develop models of care for non-surgical patients to optimize the use of scarce orthopaedic surgeon resources and to enhance the management of musculoskeletal disorders across the care continuum.
doi:10.1371/journal.pone.0065560
PMCID: PMC3672140  PMID: 23750266
3.  Magnitude of impact and healthcare use for musculoskeletal disorders in the paediaric: a population-based study 
Background
Although musculoskeletal disorders (MSD) are among the most prevalent chronic conditions, minimal attention has been paid to the paediatric population. The aim of this study is to describe the annual prevalence of healthcare contacts for MSD by children and youth age 0-19 years, including type of MSD, care delivery setting and the specialty of the physician consulted.
Methods
Analysis of data on all children with healthcare contacts for MSD in Ontario, Canada using data from universal health insurance databases on ambulatory physician and emergency department (ED) visits, same-day outpatient surgery, and in-patient admissions for the fiscal year 2006/07. The proportion of children and youth seeing different physician specialties was calculated for each physician and condition grouping. Census data for the 2006 Ontario population was used to calculate person visit rates.
Results
122.1 per 1,000 children and youth made visits for MSD. The majority visited for injury and related conditions (63.2 per 1,000), followed by unspecified MSD complaints (33.0 per 1,000), arthritis and related conditions (27.7 per 1,000), bone and spinal conditions (14.2 per 1,000), and congenital anomalies (3 per 1,000). Injury was the most common reason for ED visits and in-patient admissions, and arthritis and related conditions for day-surgery. The majority of children presented to primary care physicians (74.4%), surgeons (22.3%), and paediatricians (10.1%). Paediatricians were more likely to see younger children and those with congenital anomalies or arthritis and related conditions.
Conclusion
One in eight children and youth make physician visits for MSD in a year, suggesting that the prevalence of MSD in children may have been previously underestimated. Although most children may have self-limiting conditions, it is unknown to what extent these may deter involvement in physical activity, or be indicators of serious and potentially life-threatening conditions. Given deficiencies in medical education, particularly of primary care physicians and paediatricians, it is important that training programs devote an appropriate amount of time to paediatric MSD.
doi:10.1186/1471-2474-13-98
PMCID: PMC3493363  PMID: 22691633
4.  A population-based study of ambulatory and surgical services provided by orthopaedic surgeons for musculoskeletal conditions 
Background
The ongoing process of population aging is associated with an increase in prevalence of musculoskeletal conditions with a concomitant increase in the demand of orthopaedic services. Shortages of orthopaedic services have been documented in Canada and elsewhere. This population-based study describes the number of patients seen by orthopaedic surgeons in office and hospital settings to set the scene for the development of strategies that could maximize the availability of orthopaedic resources.
Methods
Administrative data from the Ontario Health Insurance Plan and Canadian Institute for Health Information hospital separation databases for the 2005/06 fiscal year were used to identify individuals accessing orthopaedic services in Ontario, Canada. The number of patients with encounters with orthopaedic surgeons, the number of encounters and the number of surgeries carried out by orthopaedic surgeons were estimated according to condition groups, service location, patient's age and sex.
Results
In 2005/06, over 520,000 Ontarians (41 per 1,000 population) had over 1.3 million encounters with orthopaedic surgeons. Of those 86% were ambulatory encounters and 14% were in hospital encounters. The majority of ambulatory encounters were for an injury or related condition (44%) followed by arthritis and related conditions (37%). Osteoarthritis accounted for 16% of all ambulatory encounters. Orthopaedic surgeons carried out over 140,000 surgeries in 2005/06: joint replacement accounted for 25% of all orthopaedic surgeries, whereas closed repair accounted for 16% and reductions accounted for 21%. Half of the orthopaedic surgeries were for arthritis and related conditions.
Conclusion
The large volume of ambulatory care points to the significant contribution of orthopaedic surgeons to the medical management of chronic musculoskeletal conditions including arthritis and injuries. The findings highlight that surgery is only one component of the work of orthopaedic surgeons in the management of these conditions. Policy makers and orthopaedic surgeons need to be creative in developing strategies to accommodate the growing workload of orthopaedic surgeons without sacrificing quality of care of patients with musculoskeletal conditions.
doi:10.1186/1472-6963-9-56
PMCID: PMC2682488  PMID: 19335904

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