Effect of waiting time on health outcomes and service utilization : A prospective randomized study on patients admitted to hospital for hip or knee replacement

Although the principle of equal access to medically justified treatment has been promoted by official health policies in many Western health care systems, practices do not completely meet policy targets. Waiting times for elective surgery vary between patient groups and regions, and growing problems in the availability of services threaten equal access to treatment. Waiting times have come to the attention of decision-makers, and several policy initiatives have been introduced to ensure the availability of care within a reasonable time. In Finland, for example, the treatment guarantee came into force in 2005. However, no consensus exists on optimal waiting time for different patient groups. The purpose of this multi-centre randomized controlled trial was to analyse health-related quality of life, pain and physical function in total hip or knee replacement patients during the waiting time and to evaluate whether the waiting time is associated with patients health outcomes at admission. This study also assessed whether the length of waiting time is associated with social and health services utilization in patients awaiting total hip or knee replacement. In addition, patients health-related quality of life was compared with that of the general population. Consecutive patients with a need for a primary total hip or knee replacement due to osteoarthritis were placed on the waiting list between August 2002 and November 2003. Patients were randomly assigned to a short waiting time (maximum 3 months) or a non-fixed waiting time (waiting time not fixed in advance, instead the patient followed the hospitals routine practice). Patients health-related quality of life was measured upon being placed on the waiting list and again at hospital admission using the generic 15D instrument. Pain and physical function were evaluated using the self-report Harris Hip Score for hip patients and a scale modified from the Knee Society Clinical Rating System for knee patients. Utilization measures were the use of home health care, rehabilitation and social services, physician visits and inpatient care. Health and social services use was low in both waiting time groups. The most common services used while waiting were rehabilitation services and informal care, including unpaid care provided by relatives, neighbours and volunteers. Although patients suffered from clear restrictions in usual activities and physical functioning, they seemed primarily to lean on informal care and personal networks instead of professional care. While longer waiting time did not result in poorer health-related quality of life at admission and use of services during the waiting time was similar to that at the time of placement on the list, there is likely to be higher costs of waiting by people who wait longer simply because they are using services for a longer period. In economic terms, this would represent a negative impact of waiting. Only a few reports have been published of the health-related quality of life of patients awaiting total hip or knee replacement. These findings demonstrate that, in addition to physical dimensions of health, patients suffered from restrictions in psychological well-being such as depression, distress and reduced vitality. This raises the question of how to support patients who suffer from psychological distress during the waiting time and how to develop strategies to improve patients initiatives to reduce symptoms and the burden of waiting. Key words: waiting time, total hip replacement, total knee replacement, health-related quality of life, randomized controlled trial, outcome assessment, social service, utilization of health services

Finnish-French Fundamental Cultural Antagonisms in Organising

Seeking to challenge the belief that within-West cultural differences should be seen as insignificant in organisations, this paper seeks to demonstrate how two given Western European ‘organising cultures’ (i.e. Finnish culture and French culture, as they are expressed in the process of organising) can contrast, if not conflict, with each other. Further, it aims to help the reader realise what kinds of fundamental ‘cultural antagonisms’ these contrasting organising behaviours may come from, to help her/him understand ‘the other culture’ better, and thus allow for a first step towards an improvement of Finnish-French intercultural interactions in organisational contexts. After shortly introducing what should be understood here as ‘cultural antagonisms’, the paper addresses four fundamental Finnish-French antagonisms, regarding the vision of the organisation (‘functionalist vs. personalist’), the relative importance of ‘consensus vs. dissensus’, the typical trade-off between reliability and flexibility, and the striking differences in communication, respectively. These four fundamental antagonisms are found to be closely interrelated and integrated, serving as explanation, justification and legitimisation for each other. That does not mean, however, that differences, however striking they may be, should merely be a threat to co-operation: some implications introduced at the end of the paper suggest that, provided people are aware of them, cultural antagonisms can also be seen as opportunities for a more fruitful work interaction.