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Doctors routinely deny hip- and knee-replacement surgery to deserving patients because they may not have access to the services necessary to help them recover, according to a new study by Canadian researchers.

The findings suggest that healthier patients who don't require much post-operative support may be more likely to receive joint-replacement surgery, raising troubling questions about the health status of weaker patients who could benefit from the surgery.

"Physicians, because of the constraints of the health-care system, are in a very difficult situation and are required to prioritize patients [based] not just on their need but on system issues," said Jim Wright, a surgery professor at the University of Toronto and one of the study's authors.

Pressures on the system, including long waiting lists, lack of access to operating rooms and limited post-operative support, are turning physicians into brokers, forcing them to determine which patients are "the 'best' rather than simply appropriate candidates" for joint-replacement surgery, according to the study, published this week in the journal Medical Decision Making.

That means some patients who are good candidates may be denied access to surgery because post-operative care is unavailable.

"People who are the fittest may get joint replacement," said Pamela Hudak, the study's lead author and a research scientist at the Keenan Research Centre at St. Michael's Hospital. "Physicians are ... in an extremely hard position."

Traditionally, doctors have viewed joint-replacement surgery on its own, independent of the types of post-operative recovery services that patients may need. But without those support services, certain patients who qualify for the surgery may not be able to get it because they may not be able to recover properly.

It's a Catch-22 that must be addressed as Canada's population ages and demand for this type of surgery increases, according to Dr. Wright.

In the study, researchers questioned 50 family doctors, rheumatologists and surgeons throughout Ontario about the factors they consider when prioritizing candidates for hip- and knee-replacement surgery.

While a patient's age and medical history play a crucial role in determining who would benefit from surgery, researchers were surprised to find that health-care system constraints "appeared to routinely influence the ultimate choice of candidates," the study said.

"We found things we didn't expect. Physicians do take the patient situation into account, but they also take the health system into account," said Dr. Hudak.

One of the major factors that seem to be keeping suitable candidates from receiving hip or knee replacements is a lack of adequate post-operative care. Some physicians interviewed as part of the study said they wouldn't refer patients for surgery if they didn't have access to home care or other rehabilitation services. As a result, older individuals or those who live alone may not get the surgery they qualify for because they may not have access to adequate recovery services.

The issue of post-operative care is significant because joint-replacement surgery is a serious procedure that has a dramatic effect on a patient's body. Younger patients who are able-bodied may be capable of recovering independently or with the help of available family members. But older patients who are generally more frail may require more intensive rehabilitative services that aren't available in some cases, according to the study. As a result, many of those patients may be denied surgery, even if they qualify for the procedure.

Dr. Wright said other parts of Canada, notably Alberta, have tried to address this problem by creating rehabilitative hospital beds for patients who may not have access to the support they need at home.

Considering that demand for joint replacements is likely to increase in the near future, it may be time for health-care organizations to address the lack of services and other problems that may be preventing some individuals from receiving surgery they could benefit from, Dr. Wright said.

"We anticipate the need for hip and knee replacements will increase before it decreases. I think this is a pretty important issue," he said.