From referral to surgical decision: a service-efficiency, cost and outcomes evaluation of general practitioner referrals to a public orthopaedic service

OBJECTIVE: Effective general practitioner (GP) referral and timely orthopaedic surgical decisions are essential for health service productivity and quality patient care, yet efficiency in this pathway is not well understood. This study evaluated GP public orthopaedic referrals up to the point of surgical determination. Aims were to estimate GP-level variability in referral volumes, types, orthopaedic resource usage, surgical conversion rates and the time and costs of orthopaedic care, up to surgical decision. METHODS: This study involved a retrospective observational cohort with cost and outcomes analysis. The 2-year cohort included all GP orthopaedic referrals to a large regional Australian public health service, orthopaedic-led care provision and costs incurred up to surgical determination (or discharge). Survival analysis used the Kaplan-Meier estimator for right censored data, with inverse probability censoring for inflation adjusted costs, expressed in Australian dollars from the health service perspective. RESULTS: A total of 18,901 referrals were identified. Referral volume was highly variable, ranging from 1 to 238 per GP. Time to surgical decision was often lengthy (mean = 520 days) and highly variable (1 week-4 years). Mean pre-surgical health service costs per referral were $785 (s.e. 11.89) and the surgical conversion rate was low (25%). Longer time periods and surgical listings were associated with greater costs. CONCLUSIONS: This large, single-centre evaluation revealed high GP referral variability, prolonged non-surgical orthopaedic care, low surgical conversion and high drop-out rates. Further research is needed to better understand the reasons behind variation in GP referral parameters and to explore ways to more efficiently align referral goals and non-surgical care across primary care and orthopaedics.