New HIQA guidelines have stipulated that patients with hip arthritis should first be managed by GPs and physiotherapists before being referred on for possible hip replacement operations.

The independent health safety body has stipulated that only arthritis patients meeting specific guidelines, outlined in a new report, should be considered for hip operations.

HIQA points out that the cost to the health sytem of providing hip replacement operations is set to rise, partly due to rising numbers of obese patients having the procedures.

The draft guidelines state that the majority of patients with hip osteoarthritis should be managed conservatively in primary care in the first instance.

Primary care treatment would include pain relief medication, weight reduction, activity programmes and physiotherapy.

HIQA says that the provision of specialist physiotherapy services for hip arthritis patients in hospitals can help cut waiting lists for outpatients appointments with consultants.

Unfortunately, access to hospital physiotherapy services is currently only available through consultant clinics, for which there can be long waiting lists, the guidelines point out.

HIQA recommends that hospital specialist physiotherapy programmes should support GPs and community physiotherapists to manage patients with arthritis who may not need operations.

It also stresses that patients should not be referred for an opinion in relation to hip surgery until there has been a discussion in relation to the pros and cons of an operation, and that they will be happy to proceed with surgery if considered suitable following assessment in primary care.

However, the guidelines state that this will require more time on the part of GPs, and means that the primary care service for managing patients with arthritis needs to be adequately resourced.

The guidelines also note that the extent to which patients must wait for their hip operations once listed for surgery is currently unclear, and it is likely that waiting lists for hip operations remain substantial.

HIQA stipulates that patients should get hip surgery only when they meet specific criteria, including:

* No improvement in the condition following at least three months of GP/physiotherapist treatment.

* These patients should have severe symptoms and/or moderate to severe movement limitation, significantly affecting their quality of life.

* Patients should also have x-ray evidence of hip osteoarthritis and have a body mass index of less than 40 (over 40 is classified as very severely obese). Obese patients are generally estimated to be at increased risk of complications around the time of surgery.

* Patients should also still want the surgery following a discussion with health professionals on its pros and cons.

HIQA says the implementation of the guidelines will depend on timely access to the full range of treatment options in primary care and to radiology services at primary care level.

The HIQA report says the current estimated annual national cost of hip replacement procedures in Ireland is €37.3 million. While the number of these operations provided in the public system has remained constant for several years, demand for this type of surgery is expected to grow.

The report adds that the cost per episode of care is also likely to increase due to rising levels of obesity, and the greater number of operative complications in obese hip replacement patients.

HIQA has also issued guidelines for carrying out shoulder and knee replacement surgery.

Director of Health Technology Assessment at HIQA Dr Mairin Ryan said the purpose of these guidelines was to ensure that the right patients receive referral and treatment at the right time and that unnecessary referrals were avoided in patients who were unlikely to get additional benefit from surgery over other treatment options.

Further details of the guidelines are available at www.hiqa.ie