Health of patients on the waiting list: Opportunity to improve health in Canada?

Barriers and facilitators to transition from pediatric to adult healthcare for immigrant youth with chronic health conditions

PURPOSE

The objective of this study was to investigate the experience of first- and second- generation immigrant youth living with chronic health conditions in Canada, their parents or caregivers, and healthcare and service providers who care for immigrant youth, regarding the transition from pediatric to adult healthcare.

DESIGN AND METHODS

We conducted semi-structured individual interviews and focus groups. Youth were 1st or 2nd generation immigrants, aged 16-25, with pediatric-onset chronic health conditions. Parents or caregivers had raised youth children as described. Providers delivered healthcare or other services to immigrant populations. Thematic analysis was conducted of all transcripts.

RESULTS

Twenty youth, 14 parents/caregivers and five service providers participated. Most participants described healthcare transition as very difficult to navigate. Two major themes emerged across participant narratives: 1. Barriers to transition: lack of family experience in Canada, language, discrimination, financial strain, stigma, and long wait times. Some of these barriers are specific to newcomer families, but others are generalizable to the Canadian population. 2. Facilitators of transition: youth independence, youth acting as cultural bridges within their families, and cross-sector support between healthcare, education, social work and settlement services.

CONCLUSIONS

Immigrant youth and their families face a broad range of barriers to healthcare transition. The collaborative nature of cross-sector support effectively addressed some of the barriers faced by newcomer families.

PRACTICE IMPLICATIONS

Clinicians should provide immigrant youth and their families with accessible information about the health condition and how to navigate the adult healthcare system prior to transition, particularly when language barriers exist.

Codesign of health technology interventions to support best-practice perioperative care and surgical waitlist management

OBJECTIVES

This project aimed to determine where health technology can support best-practice perioperative care for patients waiting for surgery.

METHODS

An exploratory codesign process used personas and journey mapping in three interprofessional workshops to identify key challenges in perioperative care across four health districts in Sydney, Australia. Through participatory methodology, the research inquiry directly involved perioperative clinicians. In three facilitated workshops, clinician and patient participants codesigned potential digital interventions to support perioperative pathways. Workshop output was coded and thematically analysed, using design principles.

RESULTS

Codesign workshops, involving 51 participants, were conducted October to November 2022. Participants designed seven patient personas, with consumer representatives confirming acceptability and diversity. Interprofessional team members and consumers mapped key clinical moments, feelings and barriers for each persona during a hypothetical perioperative journey. Six key themes were identified: 'preventative care', 'personalised care', 'integrated communication', 'shared decision-making', 'care transitions' and 'partnership'. Twenty potential solutions were proposed, with top priorities a digital dashboard and virtual care coordination.

DISCUSSION

Our findings emphasise the importance of interprofessional collaboration, patient and family engagement and supporting health technology infrastructure. Through user-based codesign, participants identified potential opportunities where health technology could improve system efficiencies and enhance care quality for patients waiting for surgical procedures. The codesign approach embedded users in the development of locally-driven, contextually oriented policies to address current perioperative service challenges, such as prolonged waiting times and care fragmentation.

CONCLUSION

Health technology innovation provides opportunities to improve perioperative care and integrate clinical information. Future research will prototype priority solutions for further implementation and evaluation.

A self-managed exercise therapy program for wrist osteoarthritis: study protocol for a randomized controlled trial

BACKGROUND

Post-traumatic wrist osteoarthritis (OA) can eventually lead to pain, muscular weakness, and stiffness of the wrist, which can affect the function of the entire upper limb and reduce the quality of life. Although there is strong evidence that all patients with OA should be offered adequate education and exercises as a first-line treatment, an effective self-management program, including structured education and therapeutic exercises, has not yet been introduced for individuals with wrist OA. This trial aims to evaluate the effectiveness of an exercise therapy program with joint protective strategies to improve neuromuscular control (intervention group) compared to a training program with range of motion exercises (control group).

METHODS

This is a single-blinded randomized controlled trial (RCT) with two treatment arms in patients with symptomatic and radiographically confirmed wrist OA. The trial will be conducted at a hand surgery department. The participants will be randomly assigned either to a neuromuscular exercise therapy program or to a training program with range of motion exercises only. Participants in both groups will receive a wrist orthosis and structured education on wrist anatomy, pathophysiology, and joint protective self-management strategies. The programs consist of home exercises that will be performed twice a day for 12 weeks. The Patient-Rated Wrist Evaluation (PRWE) is the primary outcome measure of pain and function. Wrist range of motion (ROM), grip strength, the Numeric Pain Rating scale (NPRS), Disabilities of the Arm, Shoulder, and Hand (DASH), the General Self-Efficacy Scale (GSES), Global Rating of Change (GROC), and conversion to surgery are the secondary measures of outcome. Assessments will be performed at baseline and at 3, 6, and 12 months after baseline by a blinded assessor.

DISCUSSION

The upcoming results from this trial may add new knowledge about the effectiveness of a self-managed exercise therapy program on pain and function for individuals with wrist OA. If the present self-management program proves to be effective, it can redefine current treatment strategies and may be implemented in wrist OA treatment protocols.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05367817. Retrospectively registered on 27 April 2022. https://clinicaltrials.gov .

Managing surgical waiting lists through dynamic priority scoring

Prioritising elective surgery patients under the Australian three-category system is inherently subjective due to variability in clinician decision making and the potential for extraneous factors to influence category assignment. As a result, waiting time inequities can exist which may lead to adverse health outcomes and increased morbidity, especially for patients deemed to be low priority. This study investigated the use of a dynamic priority scoring (DPS) system to rank elective surgery patients more equitably, based on a combination of waiting time and clinical factors. Such a system enables patients to progress on the waiting list in a more objective and transparent manner, at a rate relative to their clinical need. Simulation results comparing the two systems indicate that the DPS system has potential to assist in managing waiting lists by standardising waiting times relative to urgency category, in addition to improving waiting time consistency for patients of similar clinical need. In clinical practice, this system is likely to reduce subjectivity, increase transparency, and improve overall efficiency of waiting list management by providing an objective metric to prioritise patients. Such a system is also likely to increase public trust and confidence in the systems used to manage waiting lists.

Prevalence of diagnosable depression in patients awaiting orthopaedic specialist consultation: a cross-sectional analysis

BACKGROUND

Musculoskeletal conditions, including osteoarthritis (OA), are a leading cause of disability and chronic pain, and are associated with high rates of comorbid depression. However, signs of depression are often masked by pain. The aim of this study was to determine the prevalence and severity of depression and pain in individuals awaiting specialist orthopaedic consultation. A secondary objective was to determine the relationship between pain and depression, irrespective of demographic factors and clinical diagnosis.

METHODS

Cross-sectional analysis of individuals awaiting orthopaedic consultation at a public hospital in Melbourne, Australia. Relevant data were extracted from medical records and questionnaires. Descriptive statistics were used to summarise participant characteristics. The patient health questionnaire (PHQ-9) was used to assess depression and a numerical rating scale (NRS) was used to assess pain severity. Multiple linear regression analyses were used to establish the relationship between pain and depression.

RESULTS

Nine hundred and eighty-six adults (mean ± standard deviation, age = 54.1 ± 15.7 years, 53.2% women) participated in the study. OA was present in 56% of the population and 34% of the entire population had moderate depression or greater, 19% of which met the criteria for major depressive disorder. Moderate-to-severe pain was present in 79% of individuals with OA and 55% of individuals with other musculoskeletal complaints. Pain was significantly associated with depression scores (β = 0.84, adjusted R² = 0.13, P < 0.001), and this relationship remained significant after accounting for gender, age, education and employment status, OA status, number of joints affected and waiting time (β = 0.91, adjusted R² = 0.19, P < 0.001).

CONCLUSIONS

Depression affects one-third of individuals on an orthopaedic waitlist. A strong link between pain and depression in patients awaiting specialist orthopaedic consultation exists, indicating a need for an integrated approach in addressing pain management and depression to manage this complex and comorbid presentation.

Dynamic Surgical Waiting List Methodology: A Networking Approach

In Chile and the world, the supply of medical hours to provide care has been reduced due to the health crisis caused by COVID-19. As of December 2021, the outlook has been critical in Chile, both in medical and surgical care, where 1.7 million people wait for care, and the wait for surgery has risen from 348 to 525 days on average. This occurs mainly when the demand for care exceeds the supply available in the public system, which has caused serious problems in patients who will remain on hold and health teams have implemented management measures through prioritization measures so that patients are treated on time. In this paper, we propose a methodology to work in net for predicting the prioritization of patients on surgical waiting lists (SWL) embodied with a machine learning scheme for a high complexity hospital (HCH) in Chile. That is linked to the risk of each waiting patient. The work presents the following contributions; The first contribution is a network method that predicts the priority order of anonymous patients entering the SWL. The second contribution is a dynamic quantification of the risk of waiting patients. The third contribution is a patient selection protocol based on a dynamic update of the SWL based on the components of prioritization, risk, and clinical criteria. The optimization of the process was measured by a simulation of the total times of the system in HCH. The prioritization strategy proposed savings of medical hours allowing 20% additional surgeries to be performed, thus reducing SWL by 10%. The risk of waiting patients could drop by up to 8% annually. We hope to implement this methodology in real health care units.

Provider supply and access to primary care

Resource-constrained delivery systems often have access issues, causing patients to wait a long time to see a provider. We develop theoretical and empirical models of wait times and apply them to primary care delivery by the U.S. Veterans Health Administration (VHA). Using instrumental variables to handle simultaneity issues, we estimate the effect of clinician supply on new patient wait times. We find that it has a sizable impact. A 10% increase in capacity reduces wait times by 2.1%. Wait times are also associated with clinician productivity, scheduling protocols, and patient access to alternative sources of care. The VHA has adopted our models to identify underserved areas as specified by the MISSION Act of 2018.

The impact of wait time on patient outcomes in knee and hip replacement surgery: a scoping review protocol

BACKGROUND

Total hip and total knee replacement surgery are in high demand, leading to long wait times for many patients. While on the waiting list, patients may experience worsening pain, reduced mobility, and deteriorating health. Given that long wait times are common for lower joint replacement surgery, it is important to understand how patient health changes during the wait period and whether this impacts patient outcomes after surgery. The aim of this scoping review will be to identify and describe the evidence regarding the impact of wait time on patient outcomes for patients who undergo total knee and total hip replacement surgery.

METHODS

This scoping review was designed with guidance from the Joanna Briggs Institute Manual for Evidence Synthesis, and results will be reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. EMBASE, Medline, PubMed, Scopus, CINAHL, and Cochrane electronic databases will be searched for English language articles published after 1999. Studies of adult patients with osteoarthritis undergoing primary knee or hip replacement surgery, which measure patient outcomes over the wait period for surgery, will be included. Two independent reviewers will screen titles and abstracts followed by full article review. Data will be extracted by two reviewers using a standardized form. Outcomes assessed during the wait period will be identified and described in tables. Factors associated with changes in health status during the wait period will be qualitatively described.

DISCUSSION

This review will map the evidence regarding wait times for lower extremity joint replacement surgery. Better understanding of how the impact of wait times on patient health status is measured over the perioperative period will inform future research on wait times.

SCOPING REVIEW REGISTRATION

Registered with Open Science Framework, Feb 14, 2021 DOI: https://doi.org/10.17605/OSF.IO/MV4FS.

Improving Access for Priority Patient Populations Within Outpatient Specialty Practices

In an outpatient health care practice, it can be challenging to convert patient demand into completed appointments, even for high-priority patients. One of the barriers to higher conversion rates is excessive appointment lag time, which can lead to nonattendance or cancellation for other reasons. In this article, we develop a mechanism for reducing appointment lag time for priority patient populations. We report on a pilot program with 12 practices, split into pilot and control groups, and involving 11001 patients requesting new appointments. The results of the pilot show that statistically significant improvements to conversion rates can be achieved.

Patient prioritisation methods to shorten waiting times for elective surgery: A systematic review of how to improve access to surgery

BACKGROUND

Concern about long waiting times for elective surgeries is not a recent phenomenon, but it has been heightened by the impact of the COVID-19 pandemic and its associated measures. One way to alleviate the problem might be to use prioritisation methods for patients on the waiting list and a wide range of research is available on such methods. However, significant variations and inconsistencies have been reported in prioritisation protocols from various specialties, institutions, and health systems. To bridge the evidence gap in existing literature, this comprehensive systematic review will synthesise global evidence on policy strategies with a unique insight to patient prioritisation methods to reduce waiting times for elective surgeries. This will provide evidence that might help with the tremendous burden of surgical disease that is now apparent in many countries because of operations that were delayed or cancelled due to the COVID-19 pandemic and inform policy for sustainable healthcare management systems.

METHODS

We searched PubMed, EMBASE, SCOPUS, Web of Science, and the Cochrane Library, with our most recent searches in January 2020. Articles published after 2013 on major elective surgery lists of adult patients were eligible, but cancer and cancer-related surgeries were excluded. Both randomised and non-randomised studies were eligible and the quality of studies was assessed with ROBINS-I and CASP tools. We registered the review in PROSPERO (CRD42019158455) and reported it in accordance with the PRISMA statement.

RESULTS

The electronic search in five bibliographic databases yielded 7543 records (PubMed, EMBASE, SCOPUS, Web of Science, and Cochrane) and 17 eligible articles were identified in the screening. There were four quasi-experimental studies, 11 observational studies and two systematic reviews. These demonstrated moderate to low risk of bias in their research methods. Three studies tested generic approaches using common prioritisation systems for all elective surgeries in common. The other studies assessed specific prioritisation approaches for re-ordering the waiting list for a particular surgical specialty.

CONCLUSIONS

Explicit prioritisation tools with a standardised scoring system based on clear evidence-based criteria are likely to reduce waiting times and improve equitable access to health care. Multiple attributes need to be considered in defining a fair prioritisation system to overcome limitations with local variations and discriminations. Collating evidence from a diverse body of research provides a single framework to improve the quality and efficiency of elective surgical care provision in a variety of health settings. Universal prioritisation tools with vertical and horizontal equity would help with re-ordering patients on waiting lists for elective surgery and reduce waiting times.

The psychological burden of waiting for procedures and patient-centred strategies that could support the mental health of wait-listed patients and caregivers during the COVID-19 pandemic: A scoping review

BACKGROUND

Waiting for procedures delayed by COVID-19 may cause anxiety and related adverse consequences.

OBJECTIVE

To synthesize research on the mental health impact of waiting and patient-centred mitigation strategies that could be applied in the COVID-19 context.

METHODS

Using a scoping review approach, we searched 9 databases for studies on waiting lists and mental health and reported study characteristics, impacts and intervention attributes and outcomes.

RESULTS

We included 51 studies that focussed on organ transplant (60.8%), surgery (21.6%) or cancer management (13.7%). Most patients and caregivers reported anxiety, depression and poor quality of life, which deteriorated with increasing wait time. The impact of waiting on mental health was greater among women and new immigrants, and those of younger age, lower socio-economic status, or with less-positive coping ability. Six studies evaluated educational strategies to develop coping skills: 2 reduced depression (2 did not), 1 reduced anxiety (2 did not) and 2 improved quality of life (2 did not). In contrast, patients desired acknowledgement of concerns, peer support, and periodic communication about wait-list position, prioritization criteria and anticipated procedure date.

CONCLUSIONS

Findings revealed patient-centred strategies to alleviate the mental health impact of waiting for procedures. Ongoing research should explore how to optimize the impact of those strategies for diverse patients and caregivers, particularly in the COVID-19 context.

PATIENT OR PUBLIC CONTRIBUTION

Six patients and four caregivers waiting for COVID-19-delayed procedures helped to establish eligibility criteria, plan data extraction and review a draft and final report.

Patients’ Prioritization on Surgical Waiting Lists: A Decision Support System

Currently, in Chile, more than a quarter-million of patients are waiting for an elective surgical intervention. This is a worldwide reality, and it occurs as the demand for healthcare is vastly superior to the clinical resources in public systems. Moreover, this phenomenon has worsened due to the COVID-19 sanitary crisis. In order to reduce the impact of this situation, patients in the waiting lists are ranked according to a priority. However, the existing prioritization strategies are not necessarily systematized, and they usually respond only to clinical criteria, excluding other dimensions such as the personal and social context of patients. In this paper, we present a decision-support system designed for the prioritization of surgical waiting lists based on biopsychosocial criteria. The proposed system features three methodological contributions; first, an ad-hoc medical record form that captures the biopsychosocial condition of the patients; second, a dynamic scoring scheme that recognizes that patients’ conditions evolve differently while waiting for the required elective surgery; and third, a methodology for prioritizing and selecting patients based on the corresponding dynamic scores and additional clinical criteria. The designed decision-support system was implemented in the otorhinolaryngology unit in the Hospital of Talca, Chile, in 2018. When compared to the previous prioritization methodology, the results obtained from the use of the system during 2018 and 2019 show that this new methodology outperforms the previous prioritization method quantitatively and qualitatively. As a matter of fact, the designed system allowed a decrease, from 2017 to 2019, in the average number of days in the waiting list from 462 to 282 days.

The effectiveness of different patient referral systems to shorten waiting times for elective surgeries: systematic review

BACKGROUND

Long waiting times for elective surgery are common to many publicly funded health systems. Inefficiencies in referral systems in high-income countries are more pronounced than lower and middle-income countries. Primary care practitioners play a major role in determining which patients are referred to surgeon and might represent an opportunity to improve this situation. With conventional methods of referrals, surgery clinics are often overcrowded with non-surgical referrals and surgical patients experience longer waiting times as a consequence. Improving the quality of referral communications should lead to more timely access and better cost-effectiveness for elective surgical care. This review summarises the research evidence for effective interventions within the scope of primary-care referral methods in the surgical care pathway that might shorten waiting time for elective surgeries.

METHODS

We searched PubMed, EMBASE, SCOPUS, Web of Science and Cochrane Library databases in December-2019 to January-2020, for articles published after 2013. Eligibility criteria included major elective surgery lists of adult patients, excluding cancer related surgeries. Both randomised and non-randomised controlled studies were eligible. The quality of evidence was assessed using ROBINS-I, AMSTAR 2 and CASP, as appropriate to the study method used. The review presentation was limited to a narrative synthesis because of heterogeneity. The PROSPERO registration number is CRD42019158455.

RESULTS

The electronic search yielded 7543 records. Finally, nine articles were considered as eligible after deduplication and full article screening. The eligible research varied widely in design, scope, reported outcomes and overall quality, with one randomised trial, two quasi-experimental studies, two longitudinal follow up studies, three systematic reviews and one observational study. All the six original articles were based on referral methods in high-income countries. The included research showed that patient triage and prioritisation at the referral stage improved timely access and increased the number of consultations of surgical patients in clinics.

CONCLUSIONS

The available studies included a variety of interventions and were of medium to high quality researches. Managing patient referrals with proper triaging and prioritisation using structured referral formats is likely to be effective in health systems to shorten the waiting times for elective surgeries, specifically in high-income countries.

Comparing patient-reported outcomes across countries: An assessment of methodological challenges

Objectives

There is little published literature on the comparison of patient-reported outcomes between countries. This study aimed to assess pre- and postoperative health among samples of patients undergoing elective groin hernia repair procedures in the National Health Service (NHS), England, and groin hernia patients in Vancouver, Canada.

Methods

We used datasets from two different sources. For the English NHS we used published anonymized patient-level data files which include the EQ-5D(3L) patient-reported outcome measure and a number of demographic and clinical characteristics. For Vancouver, we used data from a sample of Vancouver patients who completed the same instrument during a similar time frame. English patients were matched with Vancouver participant’s characteristics using propensity score methods. A linear regression model was used to measure differences in postoperative visual analogue scale values between countries, adjusting for patient characteristics.

Results

Our study revealed a range of methodological issues concerning the comparability of patient-reported outcomes following hernia repair surgery in the two health systems. These related to differences in approaches to collecting patient-reported outcome measures and the nature of explanatory variables (self-report vs. administrative data), among other challenges. As a consequence, there were differences between the matched samples and the NHS data, indicating a healthy participant bias. Unadjusted results found that Vancouver patients (N = 280) reported more problems in domains of mobility, self care, usual activities and anxiety/depression than the matched cohort of NHS patients (N = 840). Interpreting differences is challenging given different sampling designs.

Conclusions

There are significant hurdles facing comparisons of surgical patients’ outcomes between countries, including adjusting for patient differences, health system factors and approaches to survey administration. While between-country comparisons of surgical outcomes using patient-reported outcomes shows significant promise, much work on standardizing sampling design, variables and analytic methods is needed.

The minimally important difference of the Gastrointestinal Quality of Life Index for symptomatic gallstone surgery

INTRODUCTION

The Gastrointestinal Quality of Life Index (GQLI) is used to measure domains of health and symptoms among people with gastrointestinal disorders. The objective of this study is to calculate the smallest change in the GQLI that is perceived by patients as meaningful among a sample of English-speaking adult patients undergoing elective laparoscopic cholecystectomy for treatment of symptomatic gallbladder disease.

MATERIALS AND METHODS

The study is based on retrospective analyses of a sample of participants completing the GQLI and the EQ-5D(3L) preoperatively and six months postoperatively in Vancouver, Canada. Patients are excluded if they are less than 19 years of age, cannot communicate in English, or reside in a long-term care facility. The MID is calculated for the GQLI's domains using distribution and anchor-based methods.

RESULTS

Among eligible patients, the participation rate was 51%. The estimated MID for the overall GQLI value ranged between 4.32 and 11.44. There were no statistically significant differences in the GQLI's MID values between sexes or age subgroups. There were statistically significant differences in the GQLI's MID values by baseline health status.

DISCUSSION

This study should provide some comfort that the MID values used in discussing change in health and symptoms with elective cholecystectomy patients are robust to sex. Although the sample size may have been inadequate for age-based analyses, the study found large differences in MID values between age subgroups. Statistically significant differences in MID values based on preoperative health supports reporting MID values separately by baseline value. Further research should explore whether age-based differences in MID values exist using larger samples.

Variation in surgical demand and time to hip fracture repair: a Canadian database study

Background

Competing demands for operative resources may affect time to hip fracture surgery. We sought to determine the time to hip fracture surgery by variation in demand in Canadian hospitals.

Methods

We obtained discharge abstracts of 151,952 patients aged 65 years or older who underwent surgery for a hip fracture between January, 2004 and December, 2012 in nine Canadian provinces. We compared median time to surgery (in days) when demand could be met within a two-day benchmark and when demand required more days, i.e. clearance time, to provide surgery, overall and stratified by presence of medical reasons for delay.

Results

For persons admitted when demand corresponded to a 2-day clearance time, 68% of patients underwent surgery within the 2-day benchmark. When demand corresponded to a clearance time of one week, 51% of patients underwent surgery within 2 days. Compared to demand that could be served within the two-day benchmark, adjusted median time to surgery was 5.1% (95% confidence interval [CI] 4.1–6.1), 12.2% (95% CI 10.3–14.2), and 22.0% (95% CI 17.7–26.2) longer, when demand required 4, 6, and 7 or more days to clear the backlog, respectively. After adjustment, delays in median time to surgery were similar for those with and without medical reasons for delay.

Conclusion

Increases in demand for operative resources were associated with dose-response increases in the time needed for half of hip fracture patients to undergo surgery. Such delays may be mitigated through better anticipation of day-to-day supply and demand and increased response capability.

Health and Quality of Life Outcomes Among Patients Undergoing Surgery for End-Stage Ankle Arthritis

BACKGROUND

There is little research investigating which aspects of health-related quality of life change following ankle arthrodesis and total ankle replacement surgery. The objective of this study was to report on statistically and clinically relevant changes in multiple dimensions of health-related quality of life among patients undergoing ankle replacement or fusion surgery.

METHODS

This study was based on a prospective sample of ankle arthrodesis and total ankle replacement patients. Participants complete the Ankle Osteoarthritis Scale, EuroQoL's EQ-5D-3L, the Patient Health Questionnaire-9, and the pain intensity, interference with enjoyment of life, and general activity pain instrument. Instruments were completed preoperatively and postoperatively. Multivariate regression models were used to measure the change in health-related quality of life outcomes, adjusting for demographic, clinical, and health service utilization.

RESULTS

Participants achieved statistically significant improvements in health-related quality of life in each domain of measurement. The majority of participants reported clinically significant improvement in pain. Mild depressive symptoms were common, and clinically significant improvement in depression symptoms occurred in 22% of patients. Gains in health were more pronounced among participants reporting the worst preoperative health in all domains quality of life measured.

CONCLUSIONS

Pain showed a clinically important improvement among 64% of participants whereas 22% reported a clinically meaningful improvement in their depression symptoms postoperatively. Clinically significant gains in health-related quality of life were not experienced by all participants in all dimensions. Further research is warranted to better understand the failure of some patients to improve in dimensions of health studied.

LEVEL OF EVIDENCE

Level III, comparative study.

Validation of the Ankle Osteoarthritis Scale Instrument for Preoperative Evaluation of End-Stage Ankle Arthritis Patients Using Item Response Theory

BACKGROUND:

Significant ankle arthritis results in functional limitations and patient morbidity. There is a need to measure symptoms and the impact of interventions on patient's quality of life using valid and reliable patient-reported measurement instruments. The objective of this research was to validate the Ankle Osteoarthritis Scale instrument in the preoperative setting using factor analysis, item response theory, and differential item function methods.

METHODS:

This research is based on secondary analysis of patients scheduled for ankle arthrodesis or total ankle replacement in Vancouver, Canada. Participants completed the instrument between September 2014 and August 2017. Item response theory was used to estimate item difficulty and discrimination parameters, controlling for study participants' underlying level of ankle function. Differential item function was examined for sex, age group, and surgery. There were 88 participants.

RESULTS:

Modification indices suggested that item 10, "walking around the house," would better fit the pain domain rather than the disability domain. Items in the pain domain displayed a range of discrimination and difficulty. Items in the disability domain exhibited a range of discrimination, though the disability domain had low difficulty. Differential item functioning for sex, age group, and ankle arthrodesis or total ankle replacement appeared to be ignorable.

CONCLUSION:

This evaluation of the Ankle Osteoarthritis Scale found the instrument to be a strong measure of the effect of pain and dysfunction among patients with end-stage ankle arthritis, even when removing items 7 and 8, supporting its prior use in numerous clinical studies.

LEVEL OF EVIDENCE:

Level II, prospective comparative study.

Cost-Utility Study of the Economics of Bunion Correction Surgery

BACKGROUND:

Bunion correction surgery is a very common procedure to improve patients' pain and physical function attributable to a misaligned first metatarsophalangeal joint. The objective of this study was to apply a health utility framework to estimate the cost utility of bunion correction surgery.

METHODS:

Patients were prospectively recruited from the population of patients seen in a lower-extremity orthopedic clinic and scheduled for isolated bunion surgery. Participants completed EuroQoL's EQ-5D(3L) to measure patients' current general health preoperatively and 6 months postoperatively. Participants' change in quality-adjusted life years (QALYs) were calculated by comparing the difference between postoperative utility values and preoperative utility values. The study had 95 patients representing 53% of eligible patients.

RESULTS:

The mean preoperative utility value was 0.6816 and the mean postoperative value was 0.7451, a statistically significant difference denoting an improvement in self-reported health. The cost per QALY, assuming gains in health accrued for 15 years, was $4911 (the 95% confidence interval ranged from $4736 to $5088). The cost per QALY was highest among the oldest patients. Assuming gains in health accrued for 20 years, the cost per QALY was $3922.

CONCLUSION:

This study demonstrated that bunion correction surgery was inexpensive relative to its gains in health compared with commonly applied thresholds for women and men in all age groups, though the gains were not uniformly distributed across age categories. Future research should examine the impact of recurrence on the robustness of these findings.

LEVEL OF EVIDENCE:

Level III, comparative study.

Reducing wait time from referral to first visit for community outpatient services may contribute to better health outcomes: a systematic review

BACKGROUND

Many people wait long periods for community outpatient services. However little is known about the impact of waiting from referral to first visit on patient outcomes. The aim of this systematic review is to investigate whether waiting for community outpatient services is associated with adverse effects on patient outcomes.

METHODS

Medline, Embase, Psych Info and CINAHL databases were searched, combining the key concepts of waiting for healthcare and patient outcomes. Studies were included if they reported data comparing health outcomes for patients with different waiting times for the same period. Three reviewers applied inclusion and exclusion criteria to identified studies and assessed quality using the McMaster Critical Review Forms. Levels of evidence were assessed using National Health and Medical Research Council guidelines. Included studies were analysed using a descriptive synthesis, and summarised according to levels of evidence and clinical significance for key outcomes.

RESULTS

Fourteen studies that included 69,606 adult patients were selected. Selected studies included patients referred for treatment for musculoskeletal disorders (n = 28,722) or to cardiac rehabilitation (n = 40,884). There was low-level evidence that reduced wait time is associated with moderate improvement in workplace participation for patients seeking care for musculoskeletal conditions; and moderate improvement in exercise tolerance for patients referred to cardiac rehabilitation. There was inconsistent evidence that improvements in quality of life, patient satisfaction and psychological symptoms may be associated with shorter wait times. Pain, function and physical activity outcomes were not associated with wait time.

CONCLUSIONS

This review found low-level evidence suggesting an association between early access to community outpatient services and improvement of some patient outcomes. Specifically, shorter wait times from referral to first visit for musculoskeletal pain services may improve patient work participation. Shorter wait times for cardiac rehabilitation may improve patient exercise capacity. The effects of a short wait time for other patient conditions and patient outcomes, including quality of life, psychological symptoms and patient experience, are inconclusive. The modest benefits in health outcomes observed in reducing wait time for community outpatient services suggest that other possible benefits such as increasing patient flow should be explored.

TRIAL REGISTRATION

PROSPERO registration no: CRD42016047003.

Quantifying Patient-Reported Disability and Health While Waiting for Bunion Surgery

BACKGROUND

Many patients with hallux valgus progress to experiencing pain and loss of function that requires corrective surgery when nonoperative treatments fail. The primary goal of this study was to measure changes in participants' health while patients waited for their operative correction.

METHODS

Patients were prospectively recruited to complete a number of patient-reported outcome measures preoperatively. Baseline data collection was initiated in October 2014, and participants' second surveys were returned by August 2017. The setting of the study was Vancouver, Canada. There were 80 participants in the study. The participation rate among eligible patients was 52.7%.

RESULTS

The average wait time for surgery exceeded 8 months, with a mean wait of 35.7 weeks. Baseline pain among participants was high. Only in the domain of foot- and ankle-related quality of life was the duration of wait time associated with participants' change in health. The other 4 domains of foot function remained stable over the preoperative period.

CONCLUSION

Preoperative health in this study was consistent with other research showing high pain and compromised foot function among patients failing nonoperative therapies for treatment of hallux valgus. This study found high pain and compromised foot function among patients waiting for hallux valgus surgery but only minor relationships between participants' duration of wait time for operative correction of the first metatarsophalangeal joint and changes in patient-reported outcome scores.

LEVEL OF EVIDENCE

Level III, comparative study.

Psychometric validation of the Stoma-QOL questionnaire in a Canadian cross-sectional sample of colostomy and ileostomy patients

OBJECTIVES

The Stoma-QOL questionnaire is a patient-reported outcome (PRO) used to measure quality of life in patients with ileostomy or colostomy. This study assesses the Stoma-QOL's overall and item-level psychometric characteristics in patients with temporary stomas, and whether stoma-related quality of life differs by demographic characteristics.

MATERIALS AND METHODS

Analysis of cross-sectional observational PRO data from hospitals in Vancouver, Canada. Patients registered for elective ileostomy or colostomy closure, over the age of 18, and able to read English were eligible for participation. Emergent and cancer-related cases were excluded. One-way analysis of variance was used to test for demographic differences in Stoma-QOL scores. Cronbach's alpha was used for reliability, and Rasch item-response theory was used to assess overall and item characteristics.

RESULTS

120 patients were included. No statistically significant difference in Stoma-QOL scores was found by age, sex, or socioeconomic status. Reliability was 0.93. Mean item responses ranged from 1.77 to 3.55 and item-total correlation ranged from 0.51 to 0.77. The Rasch item-response theory model demonstrated significant misfit, likely due to the misfit of item 9, which asks about sexuality, and high residual correlations between item pairs 6 and 8 about fatigue, and items 16 and 17 about social relationships.

CONCLUSIONS

The Stoma-QOL questionnaire is a well-designed PRO for measuring stoma-related quality of life. Demographic variables do not appear to have a strong influence on Stoma-QOL scores. Item 9 demonstrated misfit but removal likely does not improve the instrument. Future research should focus on revising items 6, 8, 16, and 17.

Using the technology acceptance model to predict patient attitude toward personal health records in regional communities

Purpose

The purpose of this paper is to statistically measure (quantify) how a sample of Canadians perceives the usability of electronic personal health records (PHRs) and, in the process, to increase Canadian patients’ awareness of PHRs and improve physicians’ confidence in their patients’ ability to manage their own health information through PHRs.

Design/methodology/approach

The authors surveyed 325 Canadian patients living in Northern Ontario to assess a research model consisting of seven perceptions of PHR systems used to manage personal health information electronically, and to assess their perceived ability to use PHR systems. The survey questions were adapted from the 2014 National Physician Survey in Canada. The authors compared the patients’ results with physicians’ own perceptions of their patients’ ability to use PHR systems.

Findings

First, there was a positive relationship between surveyed patients’ prior experiences, needs, values, and their attitude toward adopting the PHR system. Second, how patients saw a PHR system’s user-friendliness was the strongest predictor of how useful they considered it would be. Finally, of the 243 physician respondents, 90.3 percent believed their patients would not be able to manage their own e-health information via a PHR system, but 54.8 percent of the 325 patient respondents indicated they would be able to do so.

Originality/value

This study is unique in that the authors know of no other Canadian study that purports to predict, using the technology acceptance model factors, people’s attitudes toward adopting a PHR system. As well, this is the first Canadian study to compare the perspectives of healthcare providers and their patients on e-health applications.

Evaluation of the Fecal Incontinence Quality of Life Scale (FIQL) using item response theory reveals limitations and suggests revisions

PURPOSE

The Fecal Incontinence Quality of Life Scale (FIQL) is a commonly used patient-reported outcome measure for fecal incontinence, often used in clinical trials, yet has not been validated in English since its initial development. This study uses modern methods to thoroughly evaluate the psychometric characteristics of the FIQL and its potential for differential functioning by gender.

METHODS

This study analyzed prospectively collected patient-reported outcome data from a sample of patients prior to colorectal surgery. Patients were recruited from 14 general and colorectal surgeons in Vancouver Coastal Health hospitals in Vancouver, Canada. Confirmatory factor analysis was used to assess construct validity. Item response theory was used to evaluate test reliability, describe item-level characteristics, identify local item dependence, and test for differential functioning by gender.

RESULTS

236 patients were included for analysis, with mean age 58 and approximately half female. Factor analysis failed to identify the lifestyle, coping, depression, and embarrassment domains, suggesting lack of construct validity. Items demonstrated low difficulty, indicating that the test has the highest reliability among individuals who have low quality of life. Five items are suggested for removal or replacement. Differential test functioning was minimal.

CONCLUSIONS

This study has identified specific improvements that can be made to each domain of the Fecal Incontinence Quality of Life Scale and to the instrument overall. Formatting, scoring, and instructions may be simplified, and items with higher difficulty developed. The lifestyle domain can be used as is. The embarrassment domain should be significantly revised before use.

Waiting for surgery: is waiting bad for anyone or everyone?

PURPOSE

For Canadians, as in many countries, waiting for elective surgery is expected. The duration of the wait raises questions about the maximum amount of time patients should wait for their surgery. The primary objective of this study was to test for a relationship between the length of time patients waited for elective hernia repair surgery and change in patients' self-reported health.

METHODS

This study was based on a prospectively recruited longitudinal cohort of patients waiting for elective hernia repair surgery. Participants completed the PHQ-9, PEG, EQ-5D(3L) generic instruments, and the condition-specific COMI-hernia. Multivariate regression models explored associations between patient-reported outcomes and potential confounders, including age, sex, socio-economic status, and medical comorbidities.

RESULTS

There were 118 participants and the modal age group was 61-70 years. The average wait time for participants was 22.5 weeks. There were no relationships between the duration of participants' wait for hernia repair and the change in patients' self-reported health for hernia-specific outcomes or overall health-related quality of life.

DISCUSSION

There are gains in health-related quality of life to be realized by prioritizing symptomatic patients. Participants with greater pre-operative depression, pain, and hernia-related symptoms experienced an improvement in health prior to surgery, though more clarity is needed on the mechanisms that led to improved health.

CONCLUSION

Many countries face problems with wait lists for elective surgery-and few have effective processes for triaging patients. This study shows that duration of time on the wait list was not associated with change in hernia patients' self-reported health.