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 EQ-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.