The pathway to orthopaedic surgery: a population study of the role of access to primary care and availability of orthopaedic services in Ontario, Canada

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.