The headline that caught my eye – “Hip, knee replacements spike in Atlantic Canada”- looked like a good news story. The gist of the June 21 Chronicle-Herald piece, based on a report from the Canadian Institute for Health Information (CIHI), was that between 2013 and 2018 the increase in orthopaedic surgeries in three of the four Atlantic Provinces exceeded the 17 per cent national average increase.

Newfoundland and Labrador had the biggest increase of any province – 29 per cent – followed by Nova Scotia with a 25 per cent jump and New Brunswick, up 19 per cent. Prince Edward Island was up less than two per cent.

Given the chronic concern over wait times for hip and knee replacement surgery the increased activity is welcome. But look deeper and the picture is not so rosy. People in the Maritimes still wait longer for such elective surgery than most other Canadians.

In Nova Scotia, that remains the case despite a significant increase in spending, tied to the McNeil government’s 2013 platform pledge to reduce wait times for hip and knee replacement surgery. In the latest budget, the government boasted of spending $39 million over the previous three years in an effort to “get closer to the 6-month national standard for wait times.”

Reaching the 6-month national standard would mean that those needing hip or knee replacement would receive it in six months or less. That standard is a goal that no province has reached, although some are failing less than others. In 2013, the all-province average for hip replacement was 79 per cent – meaning almost four out of five had the procedure within six months. But only 50 per cent of Nova Scotians were so fortunate. As for knees, Nova Scotia was even further removed from the national standard. Only 36 per cent received the surgery in six months or less, compared with the national average of 73 per cent.

Minor improvement

The latest CIHI data on wait times released in March shows that Nova Scotia is getting at least a modest return on its $39 million investment. For knee replacement, 47 per cent were carried out within six months in Nova Scotia, up significantly from 2013. But wait times for hip replacements grew slightly longer for Nova Scotians, with only 49 per cent of procedures meeting the six-month standard, compared with the all-province average of 75 per cent. As the table below shows, in 2018 Nova Scotia was tied with Prince Edward Island and Manitoba for worst on hip replacements and was fourth from the bottom for knee replacements. Looking on the bright side, four years earlier Nova Scotia was last in both categories.

ProvinceHip Standard metProvinceKnee Standard met
Newfoundland &Labrador88%Ontario79%
British Columbia67%British Columbia59%
New Brunswick55%Nova Scotia 47%
Prince Edward Island49%New Brunswick43%
Manitoba 49%Manitoba37%
Nova Scotia49%Prince Edward Island26%

In releasing the 2018 wait times report, CIHI made several salient points, including the observation that wait times for hip and knee replacements vary depending on where patients live. (my italics). The CIHI release contained this commentary from Dr. Eric Bohm, Orthopedic Surgeon and Canadian Joint Replacement Registry Advisory Committee Chair.

“Differences in wait times across the country are a reflection of multiple factors, including how care delivery is structured, how a patient’s wait time is measured and — most importantly, in hip and knee replacements — whether provinces are able to provide adequate resources (my italics) to meet the demand for these types of surgeries.”

As to where patients live and adequate resources, a glance at our table will show that patients living in the Maritimes or Manitoba – the less-wealthy provinces – will wait the longest. Given that the extra $39 million spent by Nova Scotia seems to have had some positive impact an argument can be made for even more spending. Perhaps limited resources spent on, say, the Yarmouth ferry should be used to reduce wait times for hip and knee replacements?

But there’s more to it than that. The release also quoted Kathleen Morris, vice president for research and analysis at CIHI.

“Reducing wait times is a complex challenge and we see from the data that increasing the number of surgeries performed won’t necessarily mean patients will experience shorter wait times. For example, Canada’s growing and aging population, as well as increases in conditions such as osteoarthritis and obesity, have contributed to a growing demand for these joint replacement procedures.”

First off, consider the number of surgeries performed, looking initially at hip replacement surgery. (At an average of $11,400 each – excluding physician cost- hip replacement surgery is 45 per cent more expensive than knee replacement). The Atlantic Provinces already exceed that national rate of 178 hip replacements per 100,000 population. Newfoundland is at 181, New Brunswick is at 183, PEI at 198 and Nova Scotia at 218 per 100,000, the highest rate in the country. As the table below shows it’s a similar story for knee replacements, although Newfoundland – despite the recent increase in surgeries – is slightly below the national average and Nova Scotia is tied with Ontario for second highest.

ProvinceHips/100,000 pop.Knees/100,000 pop.
All province average178214
Nova Scotia218245
Prince Edward Island198227
New Brunswick183232

Compared with others, the Atlantic Provinces are clearly not scrimping on the number of operations. The longer wait times are likely the result of greater demand resulting from the other factors cited by the CIHI expert – the aging population and rates of obesity and osteoarthritis.

Systemic issue

According to CIHI, degenerative arthritis, often linked with obesity, is the underlying diagnosis for 99 per cent of knee replacements and 92 per cent of hip replacements. Statistics Canada data for 2018 show that residents of Atlantic Canada report suffering from arthritis at a rate well above the national average of 19.0 per cent.

As the table below shows, for three of the four provinces there is a correlation between a low ranking on meeting the hip and knee replacement standard and a high ranking on median age and rates of obesity and arthritis, as reported by Statistics Canada for 2018.

ProvinceHip rankingKnee ranking Median ageObesity rankArthritis rank
Nova Scotia8th(T)7th3rd4th2nd
New Brunswick7th8th2nd3rd3rd
Prince Edward I. 8th(T)10th4th2nd4th

The fact that Newfoundland and Labrador ranks highest in median age and rates of obesity and arthritis while apparently doing better than the Maritime provinces at meeting the wait times standard complicates the picture. But given that the rate of orthopaedic surgeries performed in Newfoundland was lower in 2018 than in the other three provinces, the anomaly is likely the result, cited by CIHI, of provinces having different ways of measuring a patient’s wait time.

Provincial governments in this region should probably do more to reduce the rate of obesity in the population, but there’s not much to be done about the link between aging, arthritis and the demand for hip and knee replacement surgery. Currently, the choice for provinces like Nova Scotia seems to be accepting higher than average wait times or spending even more of their scarce resources to carry out a higher than average number of procedures.

In the interests of quality health care independent of where patients live, it would be better to include a needs-based component in federal health transfers to the provinces. That idea, a demographic top-up based on age and health status, was a bit of a hot topic during 2015 election campaign, before being squelched by the Trudeau government and feckless Liberal governments in the region. My most recent rendition of that sad saga can be found here.

Don’t expect the issue to play much of a role in the upcoming campaign. But if you or someone you know has been on a hip or knee replacement wait list for a year or more take whatever solace or strife you can from knowing that the problem is a systemic one, unchallenged by recent governments.