Rationing access to total hip and total knee replacement in the Islamic Republic of Iran to reduce unnecessary costs: policy brief

Abstract

Rationing health services is an inseparable part of the health system of any country in order to achieve universal health coverage. Elective surgery for total hip and total knee replacement places a high financial burden on health systems. Such surgery should be done in a way to ensure that the people who most need it receive the service. Models for rationing total hip and knee replacement surgery were reviewed to suggest the best policy for rationing such surgery in the Islamic Republic of Iran. We propose a system with three main tools: clinical guidelines, gate keepers and waiting lists, with shared decision-making as an auxiliary tool. Patients should be scored at the primary health care level based on clinical and radiographic examination, alternative treatments (conservative treatments) and risk factors, with a set threshold for referral. Patients whose scores are above the threshold should be referred to secondary health care. These patients should be assessed again by specialists based on age, bone condition, surgery risk and other alternative treatments. Patients whose scores are above the threshold should be put on the waiting list for surgery.