Ethics

Rationing Joint Replacement Surgeries: Who Gets Priority in a Resource-Limited System?

March 5, 2025

If you work in orthopaedics, you know how challenging it can be to manage long waitlists for joint replacement surgeries. Limited resources mean not everyone gets surgery as soon as they need it, forcing difficult decisions about who gets priority. Some patients endure significant pain and disability while waiting, while others manage symptoms with conservative treatments. You have to consider clinical urgency, long-term outcomes, and ethical concerns when deciding who moves up the list. The question is how to balance these factors in a way that feels fair and effective.

How priority is determined for elective surgeries

Most hospitals use structured prioritization systems for elective procedures, but you have probably seen how these frameworks don’t always reflect individual patient needs. The Federation of Surgical Specialty Associations developed a system that categorizes patients based on urgency. P1a and P1b patients need surgery within 24 to 72 hours, while P2 patients should receive surgery within a month. P3 patients have a three-month target, and P4 includes those scheduled beyond three months.

You may find that P4 is the most difficult group to manage. Some patients in this category have moderate discomfort and can function with physical therapy, while others struggle with severe pain and mobility loss. A broad classification does not always capture these differences, which can lead to patients waiting longer than they should.

Tip for better prioritization: Consider refining waitlist criteria based on patient-reported pain levels, functional limitations, and expected quality of life improvements after surgery.

Delays worsen clinical outcomes and quality of life

You probably see firsthand how long wait times affect recovery. Research shows that total knee arthroplasty patients who wait more than 180 days stay in the hospital longer after surgery, with a 2.5% increase in mean length of stay. Interestingly, this pattern does not seem to affect total hip arthroplasty patients the same way, which suggests that the impact of delays may depend on the joint involved.

You also know how much a patient’s quality of life can decline while they wait. Studies suggest that those with the lowest preoperative health-related quality of life scores experience the biggest improvements after surgery. Patients with EQ-5D-3L scores below 0.487 show the greatest postoperative gains. If prioritization were based more on current impairment than just time on the waiting list, some of the most vulnerable patients might receive surgery sooner.

Ethical concerns in rationing joint replacements

If you have had to tell a patient they do not qualify for surgery because of their body mass index, you know how frustrating these policies can be. Some hospitals restrict joint replacements for patients above a certain BMI, arguing that obesity increases surgical risks. However, the evidence behind these restrictions is weak. High BMI alone does not necessarily predict worse surgical outcomes, yet many patients must lose weight before they are even considered for surgery.

Age-based prioritization is another area that raises ethical concerns. Older patients often wait longer or are excluded from surgery entirely due to assumptions about life expectancy and recovery potential. But you probably see cases where an older, healthy patient would benefit more than a younger person with multiple comorbidities. When age alone becomes a deciding factor, some patients may be denied care they would otherwise do well with.

Avoiding bias in prioritization:

Look beyond BMI and age – Consider overall health, mobility limitations, and expected post-surgical benefits.

Use standardized scoring tools – Objective scoring systems can help reduce subjective decision-making.

Balancing economic efficiency with patient needs

If your hospital factors cost into surgical prioritization, you may be familiar with cost-utility analysis. This method compares the cost of a procedure to the number of quality-adjusted life years it provides. Joint replacements typically offer strong long-term value, but prioritizing based purely on economic efficiency risks overlooking individual patient circumstances.

You may have heard about dynamic priority scoring systems as an alternative approach. These models combine waiting time with clinical urgency to determine who should receive surgery first. Research suggests they can standardize access across different patient groups and make prioritization more equitable. If your institution has not adopted such a system yet, it may be worth considering as a way to reduce subjectivity in surgical scheduling.

Key takeaway: Economic factors will always influence resource allocation, but prioritization models should balance financial considerations with patient well-being.

The need for a fair and effective allocation system

If you are involved in scheduling joint replacement surgeries, you know how difficult it is to balance clinical urgency, quality of life considerations, and ethical concerns while working within financial constraints. Long wait times impact patient outcomes, and policies restricting access based on BMI or age create additional challenges. Alternative models, such as dynamic priority scoring, may offer a way to make allocation decisions more structured and equitable. No system will ever be perfect, but refining the process can help ensure that those who need surgery most receive it in a timely and fair manner.

Even as discussions continue on how best to distribute limited resources, the broader issue of surgical demand remains. With an aging population and rising rates of osteoarthritis, the need for joint replacements will only increase. Addressing surgical backlogs and optimizing prioritization systems will not be enough if capacity does not grow to meet demand. Expanding access to joint replacement surgery may require rethinking healthcare funding, increasing the number of trained orthopaedic surgeons, or investing in early interventions that reduce the need for surgery in the first place. Without long-term solutions, rationing will continue to be a reality, and the difficult decisions you face today may only become more frequent.