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Application of the ICF to referral delay in total joint arthroplasty
  1. Diane Dixon1,
  2. Beth Pollard2,
  3. David Rowley3,
  4. Marie Johnson2
  1. 1Department of Psychology, University of Strathclyde, Glasgow, UK
  2. 2Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
  3. 3Department of Orthopaedic and Trauma Surgery, Ninewells Hospital, Dundee, UK
  1. Correspondence to Dr Diane Dixon Department of Psychology, University of Strathclyde, 40 George Street, Glasgow G1 1QE UK; diane.dixon{at}


Background The factors that affect referral for total joint arthroplasty (TJA) have been widely studied. Implicit in this work is the assumption that patient health status should determine priority for surgery. However, specification of patient health status lacks a strong theoretical framework. This study employs the WHO model of health outcomes, the International Classification of Functioning, Disability and Health (ICF), to examine patient health factors in the referral process for TJA.

Methods Within 8 weeks prior to TJA, 260 patients electing for primary TJA completed a questionnaire which measured the ICF (impairment, activity limitations and participation restrictions) and four types of delay in their journey from initial consultation with their primary care physician to surgery.

Results Impairment did not affect any stage of the referral process. In contrast, patients who had experienced a delay of 26 weeks or less between referral to a surgeon and being placed on the waiting list for surgery reported greater activity limitations and participation restrictions than patients who had waited more than 26 weeks. Further, patients who reported having wanted surgery for more than 52 weeks reported greater participation restrictions than patients who had wanted surgery for less than 52 weeks.

Conclusions The ICF identifies three health outcomes, two of which (activity limitations and participation restrictions) are related to delay in the referral process for TJA. The ICF is a useful theoretical framework for the study of factors that influence prioritisation for surgery. The level of functional and social disability appears to inform prioritisation for TJA by consultant orthopaedic surgeons.

  • Orthopaedics
  • joint arthroplasty
  • waiting lists
  • ICF
  • referral delay

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  • Funding The Medical Research Council-Health Services Research Collaboration funded this study.

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval Ethics approval was provided by the Tayside NHS Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.