1
|
Lee SH, Kim C, Shin S, Kim H, Park JK, Oh SJ, Ahn SG, Cho S, Lee OH, Moon JY, Won H, Suh Y, Cho YH, Cho JR, Lee BK, Lee YJ, Lee SJ, Hong SJ, Shin DH, Ahn CM, Kim BK, Ko YG, Choi D, Hong MK, Jang Y, Kim JS. Perioperative Antiplatelet Strategy in Patients Undergoing Noncardiac Surgery Within One Year After Percutaneous Coronary Intervention. Am J Med 2023; 136:1026-1034.e1. [PMID: 37356644 DOI: 10.1016/j.amjmed.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/27/2023] [Accepted: 06/05/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND The optimal antiplatelet therapy (APT) for patients undergoing non-cardiac surgery within 1 year after percutaneous coronary intervention (PCI) is not yet established. METHODS Patients who underwent non-cardiac surgery within 1 year after second-generation drug-eluting stent implantation were included from a multicenter prospective registry in Korea. The primary endpoint was 30-day net adverse clinical event (NACE), including all-cause death, major adverse cardiovascular event (MACE), and major bleeding events. Covariate adjustment using propensity score was performed. RESULTS Among 1130 eligible patients, 708 (62.7%) continued APT during non-cardiac surgery. After propensity score adjustment, APT continuation was associated with a lower incidence of NACE (3.7% vs 5.5%; adjusted odds ratio [OR], 0.48; 95% confidence interval [CI], 0.26-0.89; P = .019) and MACE (1.1% vs 1.9%; adjusted OR, 0.35; 95% CI, 0.12-0.99; P = .046), whereas the incidence of major bleeding events was not different between the 2 APT strategies (1.7% vs 2.6%; adjusted OR, 0.61; 95% CI, 0.25-1.50; P = .273). CONCLUSIONS The APT continuation strategy was chosen in a substantial proportion of patients and was associated with the benefit of potentially reducing 30-day NACE and MACE with similar incidence of major bleeding events, compared with APT discontinuation. This study suggests a possible benefit of APT continuation in non-cardiac surgery within 1 year of second-generation drug-eluting stent implantation.
Collapse
Affiliation(s)
- Sang-Hyup Lee
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Choongki Kim
- Department of Cardiology, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea.
| | - Sanghoon Shin
- Department of Cardiology, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Hyeongsoo Kim
- Division of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jong-Kwan Park
- Division of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Seung-Jin Oh
- Division of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sung Gyun Ahn
- Division of Cardiology, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sungsoo Cho
- Department of Cardiology, Heart and Brain Hospital, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong, Korea
| | - Oh-Hyun Lee
- Division of Cardiology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Jae Youn Moon
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Hoyoun Won
- Cardiovascular and Arrhythmia Center, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Yongsung Suh
- Department of Cardiology, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
| | - Yun-Hyeong Cho
- Department of Cardiology, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
| | - Jung Rae Cho
- Division of Cardiology, Kangnam Sacred Heart Hospital, Hallym University Medical Center, Seoul, Korea
| | - Byoung-Kwon Lee
- Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Joon Lee
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung-Jun Lee
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Jin Hong
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong-Ho Shin
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chul-Min Ahn
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Guk Ko
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Donghoon Choi
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Myeong-Ki Hong
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yangsoo Jang
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Jung-Sun Kim
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
2
|
Powers J, McGree JM, Grieve D, Aseervatham R, Ryan S, Corry P. Managing surgical waiting lists through dynamic priority scoring. Health Care Manag Sci 2023; 26:533-557. [PMID: 37378722 PMCID: PMC10484819 DOI: 10.1007/s10729-023-09648-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/01/2023] [Indexed: 06/29/2023]
Abstract
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.
Collapse
Affiliation(s)
- Jack Powers
- School of Mathematical Sciences, Faculty of Science, Queensland University of Technology, 2 George St, Brisbane, QLD, 4000, Australia.
- Centre for Data Science, Queensland University of Technology, 2 George St, Brisbane, QLD, 4000, Australia.
| | - James M McGree
- School of Mathematical Sciences, Faculty of Science, Queensland University of Technology, 2 George St, Brisbane, QLD, 4000, Australia
- Centre for Data Science, Queensland University of Technology, 2 George St, Brisbane, QLD, 4000, Australia
| | - David Grieve
- Department of General Surgery, Surgical and Critical Care Directorate, Sunshine Coast University Hospital, 6 Doherty Street, Birtinya, QLD, 4575, Australia
- School of Medicine, Griffith University, 6 Doherty Street, Birtinya, 4575, QLD, Australia
| | - Ratna Aseervatham
- Department of General Surgery, Surgical and Critical Care Directorate, Sunshine Coast University Hospital, 6 Doherty Street, Birtinya, QLD, 4575, Australia
| | - Suzanne Ryan
- Department of General Surgery, Surgical and Critical Care Directorate, Sunshine Coast University Hospital, 6 Doherty Street, Birtinya, QLD, 4575, Australia
| | - Paul Corry
- School of Mathematical Sciences, Faculty of Science, Queensland University of Technology, 2 George St, Brisbane, QLD, 4000, Australia
- Centre for Data Science, Queensland University of Technology, 2 George St, Brisbane, QLD, 4000, Australia
| |
Collapse
|
3
|
Doshmangir L, Pourasghar F, Sharghi R, Rezapour R, Gordeev VS. Developing a prioritisation framework for patients in need of coronary artery angiography. BMC Public Health 2021; 21:1997. [PMID: 34732170 PMCID: PMC8565640 DOI: 10.1186/s12889-021-12088-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 10/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Effective waiting list management and comprehensive prioritisation can provide timely delivery of appropriate services to ensure that the patient needs are met and increase equity in the provision of health services. We developed a prioritisation framework for patients in need of coronary artery angiography (CAA). METHODS We used a multi-methods approach to elicit effective factors that affect CAA patient prioritisation. Qualitative data wase collected using semi-structured interviews with 15 experts. The final set of factors was selected using experts' consensus through modifed Delphi technique. The framework was finalised during expert panel meetings. RESULTS 212 effective factors were identified based on the literature review, interviews, and expert panel discussion of them, 37 factors were selected for modifed Delphi study. Following two rounds of Delphi discussions, seven final factors were selected and weighed by ten experts using pair-wise comparisons. The following weights were given: the severity of pain and symptoms (0.22), stress testing (0.18), background diseases (0.15), number of myocardial infarctions (0.15), waiting time (0.10), reduction of economic and social performance (0.12), and special conditions (0.08). CONCLUSION Clinical effective factors were important for CAA prioritisation framework. Using this framework can potentially lead to improved accountability and justice in the health system.
Collapse
Affiliation(s)
- Leila Doshmangir
- Social Determinants of Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Health Policy and Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Faramarz Pourasghar
- Department of Health Policy and Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Rahim Sharghi
- Department of Health Policy and Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ramin Rezapour
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Vladimir Sergeevich Gordeev
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
4
|
Kim C, Kim JS, Kim H, Ahn SG, Cho S, Lee OH, Park JK, Shin S, Moon JY, Won H, Suh Y, Cho JR, Cho YH, Oh SJ, Lee BK, Hong SJ, Shin DH, Ahn CM, Kim BK, Ko YG, Choi D, Hong MK, Jang Y. Consensus Decision-Making for the Management of Antiplatelet Therapy before Non-Cardiac Surgery in Patients Who Underwent Percutaneous Coronary Intervention With Second-Generation Drug-Eluting Stents: A Cohort Study. J Am Heart Assoc 2021; 10:e020079. [PMID: 33843258 PMCID: PMC8174156 DOI: 10.1161/jaha.120.020079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Although antiplatelet therapy (APT) has been recommended to balance ischemic‐bleeding risks, it has been left to an individualized decision‐making based on physicians' perspectives before non‐cardiac surgery. The study aimed to assess the advantages of a consensus among physicians, surgeons, and anesthesiologists on continuation and regimen of preoperative APT in patients with coronary drug‐eluting stents. Methods and Results A total of 3582 adult patients undergoing non‐cardiac surgery after percutaneous coronary intervention with second‐generation stents was retrospectively included from a multicenter cohort. Physicians determined whether APT should be continued or discontinued for a recommended period before non‐cardiac surgery. There were 3103 patients who complied with a consensus decision. Arbitrary APT, not based on a consensus decision, was associated with urgent surgery, high bleeding risk of surgery, female sex, and dual APT at the time of preoperative evaluation. Arbitrary APT independently increased the net clinical adverse event (adjusted odds ratio [ORadj], 1.98; 95% CI, 1.98–3.11), major adverse cardiac event (ORadj, 3.11; 95% CI, 1.31–7.34), and major bleeding (ORadj, 2.34; 95% CI, 1.45–3.76) risks. The association was consistently noted, irrespective of the surgical risks, recommendations, and practice on discontinuation of APT. Conclusions Most patients were treated in agreement with a consensus decision about preoperative APT based on a referral system among physicians, surgeons, and anesthesiologists. The risk of perioperative adverse events increased if complying with a consensus decision was failed. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03908463.
Collapse
Affiliation(s)
- Choongki Kim
- Department of Cardiology Ewha Womans University College of Medicine Seoul Hospital Seoul Korea
| | - Jung-Sun Kim
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Hyeongsoo Kim
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Sung Gyun Ahn
- Division of Cardiology Department of Internal Medicine Wonju Severance Christian Hospital Yonsei University Wonju College of Medicine Wonju Korea
| | - Sungsoo Cho
- Division of Cardiovascular Medicine Department of Internal Medicine Dankook University HospitalDankook University College of Medicine Cheonan Korea
| | - Oh-Hyun Lee
- Division of Cardiology Yongin Severance HospitalYonsei University College of Medicine Gyeonggi-do Korea
| | - Jong-Kwan Park
- Division of Cardiology National Health Insurance Service Ilsan Hospital Goyang Korea
| | - Sanghoon Shin
- Department of Cardiology Ewha Womans University College of Medicine Seoul Hospital Seoul Korea
| | - Jae Youn Moon
- Department of Cardiology CHA Bundang Medical Center CHA University Seongnam Korea
| | - Hoyoun Won
- Cardiovascular & Arrhythmia Center Chung-Ang University HospitalChung-Ang University College of Medicine Seoul Korea
| | - Yongsung Suh
- Department of Cardiology Myongji HospitalHanyang University College of Medicine Goyang Korea
| | - Jung Rae Cho
- Division of Cardiology Kangnam Sacred Heart Hospital Hallym University Medical Center Seoul South Korea
| | - Yun-Hyeong Cho
- Department of Cardiology Myongji HospitalHanyang University College of Medicine Goyang Korea
| | - Seung-Jin Oh
- Division of Cardiology National Health Insurance Service Ilsan Hospital Goyang Korea
| | - Byoung-Kwon Lee
- Division of Cardiology Gangnam Severance HospitalYonsei University College of Medicine Seoul South Korea
| | - Sung-Jin Hong
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Dong-Ho Shin
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Chul-Min Ahn
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Byeong-Keuk Kim
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Young-Guk Ko
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Donghoon Choi
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Myeong-Ki Hong
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Yangsoo Jang
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| |
Collapse
|
5
|
Kim C, Kim J, Kim H, Ahn SG, Cho S, Lee O, Park J, Shin S, Moon JY, Won H, Suh Y, Cho JR, Cho Y, Oh S, Lee B, Hong S, Shin D, Ahn C, Kim B, Ko Y, Choi D, Hong M, Jang Y. Patterns of Antiplatelet Therapy During Noncardiac Surgery in Patients With Second-Generation Drug-Eluting Stents. J Am Heart Assoc 2020; 9:e016218. [PMID: 32419586 PMCID: PMC7428980 DOI: 10.1161/jaha.119.016218] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/23/2020] [Indexed: 12/27/2022]
Abstract
Background Continuing antiplatelet therapy (APT) has been generally recommended during noncardiac surgery, but it is uncertain if preoperative discontinuation of APT has been avoided or harmful in patients with second-generation drug-eluting coronary stents. Methods and Results Patients undergoing noncardiac surgery after second-generation drug-eluting coronary stent implantation were assessed in a multicenter cohort in Korea. Net adverse clinical events within 30 days postoperatively, defined as all-cause death, major adverse cardiac events, and major bleeding, were evaluated. Of 3582 eligible patients, 49% patients discontinued APT during noncardiac surgery. The incidence of net adverse clinical events was comparable between patients with continuation versus discontinuation (4.1% versus 3.4%; P=0.257) of APT during noncardiac surgery. Perioperative discontinuation of APT did not impact on net adverse clinical events (adjusted hazard ratio [HR], 1.00; 95% CI, 0.69-1.44; P=0.995). In subgroup analysis, patients undergoing intra-abdominal surgery were exposed to less risk of major bleeding by discontinuing APT (adjusted HR, 0.26; 95% CI, 0.08-0.91; P=0.035). Prolonged discontinuation of APT for ≥9 days was associated with higher risk of a major adverse cardiac event compared with continuing APT (adjusted HR, 3.38; 95% CI, 1.36-8.38; P=0.009). Conclusions APT was discontinued preoperatively in almost half of patients with second-generation drug-eluting coronary stents. Our explorative analysis showed that there was no significant impact of discontinuing APT on the risk of perioperative adverse events except that discontinuing APT may be associated with decreased hemorrhagic risk in patients undergoing intra-abdominal surgery. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03908463.
Collapse
Affiliation(s)
- Choongki Kim
- Department of CardiologyEwha Womans University College of Medicine Seoul HospitalSeoulKorea
- Division of CardiologyDepartment of Internal MedicineSeverance Cardiovascular HospitalYonsei University College of MedicineSeoulKorea
| | - Jung‐Sun Kim
- Division of CardiologyDepartment of Internal MedicineSeverance Cardiovascular HospitalYonsei University College of MedicineSeoulKorea
| | - Hyeongsoo Kim
- Division of CardiologyDepartment of Internal MedicineSeverance Cardiovascular HospitalYonsei University College of MedicineSeoulKorea
| | - Sung Gyun Ahn
- Division of CardiologyDepartment of Internal MedicineWonju Severance Christian HospitalYonsei University Wonju College of MedicineWonjuKorea
| | - Sungsoo Cho
- Division of Cardiovascular MedicineDepartment of Internal MedicineDankook University HospitalDankook University College of MedicineCheonanKorea
| | - Oh‐Hyun Lee
- Division of CardiologyYongin Severance HospitalYonsei University College of MedicineGyeonggi‐doKorea
| | - Jong‐Kwan Park
- Division of CardiologyNational Health Insurance Service Ilsan HospitalGoyangKorea
| | - Sanghoon Shin
- Department of CardiologyEwha Womans University College of Medicine Seoul HospitalSeoulKorea
| | - Jae Youn Moon
- Department of CardiologyCHA Bundang Medical CenterCHA UniversitySeongnamKorea
| | - Hoyoun Won
- Cardiovascular & Arrhythmia CenterChung‐Ang University HospitalChung‐Ang University College of MedicineSeoulKorea
| | - Yongsung Suh
- Department of CardiologyMyongji HospitalHanyang University College of MedicineGoyangKorea
| | - Jung Rae Cho
- Division of CardiologyKangnam Sacred Heart HospitalHallym University Medical CenterSeoulSouth Korea
| | - Yun‐Hyeong Cho
- Department of CardiologyMyongji HospitalHanyang University College of MedicineGoyangKorea
| | - Seung‐Jin Oh
- Division of CardiologyNational Health Insurance Service Ilsan HospitalGoyangKorea
| | - Byoung‐Kwon Lee
- Division of CardiologyGangnam Severance HospitalYonsei University College of MedicineSeoulSouth Korea
| | - Sung‐Jin Hong
- Division of CardiologyDepartment of Internal MedicineSeverance Cardiovascular HospitalYonsei University College of MedicineSeoulKorea
| | - Dong‐Ho Shin
- Division of CardiologyDepartment of Internal MedicineSeverance Cardiovascular HospitalYonsei University College of MedicineSeoulKorea
| | - Chul‐Min Ahn
- Division of CardiologyDepartment of Internal MedicineSeverance Cardiovascular HospitalYonsei University College of MedicineSeoulKorea
| | - Byeong‐Keuk Kim
- Division of CardiologyDepartment of Internal MedicineSeverance Cardiovascular HospitalYonsei University College of MedicineSeoulKorea
| | - Young‐Guk Ko
- Division of CardiologyDepartment of Internal MedicineSeverance Cardiovascular HospitalYonsei University College of MedicineSeoulKorea
| | - Donghoon Choi
- Division of CardiologyDepartment of Internal MedicineSeverance Cardiovascular HospitalYonsei University College of MedicineSeoulKorea
| | - Myeong‐Ki Hong
- Division of CardiologyDepartment of Internal MedicineSeverance Cardiovascular HospitalYonsei University College of MedicineSeoulKorea
| | - Yangsoo Jang
- Division of CardiologyDepartment of Internal MedicineSeverance Cardiovascular HospitalYonsei University College of MedicineSeoulKorea
| |
Collapse
|
6
|
Curtis AJ, Wolfe R, Russell COH, Elliott BG, Hart JAL, McNeil JJ. Determining priority for joint replacement: comparing the views of orthopaedic surgeons and other professionals. Med J Aust 2012; 195:699-702. [PMID: 22171869 DOI: 10.5694/mja10.11052] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess which patient characteristics influence the assessments of urgency for surgery by orthopaedic surgeons and non-orthopaedic professionals. DESIGN, SETTING AND PARTICIPANTS Cross-sectional study of 80 patients requiring elective hip or knee replacement attending a public hospital orthopaedic outpatient clinic or orthopaedic surgeon's private rooms. Patients were interviewed after being placed on the surgery waiting list. The interview asked about the severity of their joint disease and its effects on physical capability, psychological distress and social circumstances. Patient interviews were summarised and presented to assessors who ranked groups of eight patients in order of their perceived urgency for surgery. Eleven orthopaedic surgeon assessors completed 360 patient ratings and nine non-orthopaedic assessors from various professions, including physiotherapy, social work, research, management and engineering, completed 720 patient ratings. MAIN OUTCOME MEASURES Visual analogue scale rating of patient urgency for surgery; patient rankings for surgery; scores for individual domain contributions to urgency rating. RESULTS A broad spread of perceived urgency was evident among the patients. For each group of eight patients, there was moderate agreement on overall urgency rankings between the two groups of assessors. Linear regression demonstrated that pain was the dominant determinant of urgency score for both assessor groups. Orthopaedic surgeons also took into account limitations to mobility and concurrent medical illness but gave less priority to psychological distress or social circumstances. For the non-orthopaedic assessors, limitations to mobility, social circumstances and psychological distress also contributed to urgency. CONCLUSION Both orthopaedic surgeons and non-orthopaedic professionals considered pain the most important factor in establishing urgency and priority for joint replacement. Only the non-orthopaedic professionals considered psychosocial factors important when determining priority for surgery. Broader community discussion about prioritisation for elective surgery is needed to facilitate agreement about which patients factors should be considered.
Collapse
Affiliation(s)
- Andrea J Curtis
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC.
| | | | | | | | | | | |
Collapse
|
7
|
Abstract
OBJECTIVES The aim of this paper was to compare selected indication parameters for patients scheduled for hip and knee replacement at orthopaedic units in Sweden. METHODS Swedish orthopaedic clinics performing joint replacement were invited to enroll in the study. The study time was set to 2 years (from June 2006 to June 2008). The study subjects were patients undergoing hip or knee replacement for osteoarthritis (OA). For data collection, we used a Swedish priority criteria tool based on a translation from a form used in Canada with minor changes. The reliability and validity of the Swedish tool were investigated, with good reproducibility. The questionnaires (one for the doctor and one for the patient) were completed during decision making for surgery. RESULTS Eleven hospitals enrolled in the study. In total, 2961 patients were included during the study period. Among these, 1662 were hip replacement patients and 1299 were knee replacement patients. The vast majority of patients undergoing hip or knee replacement had findings indicating severe OA, both clinically and radiologically according to the clinical priority tool. Statistically significant self-reported problems with pain at rest, walking and impaired activities of daily living were also observed. There were statistically significant differences in reported indications between the hospitals, both for hip OA patients and for knee OA patients. CONCLUSIONS A clinical priority criteria tool is a useful means of following changes in indications for certain procedures. It could also contribute to explaining differences in case mix when evaluating clinical outcome and patient satisfaction.
Collapse
Affiliation(s)
- Sofia Löfvendahl
- Swedish National Musculoskeletal Competence Centre (NKO), Lund University Hospital, Lund University, Lund, Sweden.
| | | | | | | |
Collapse
|
8
|
Curtis AJ, Russell COH, Stoelwinder JU, McNeil JJ. Waiting lists and elective surgery: ordering the queue. Med J Aust 2010; 192:217-20. [DOI: 10.5694/j.1326-5377.2010.tb03482.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2009] [Accepted: 10/07/2009] [Indexed: 11/17/2022]
Affiliation(s)
- Andrea J Curtis
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC
| | - Colin O H Russell
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC
- Department of Surgery, Monash University, Melbourne, VIC
| | | | - John J McNeil
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC
| |
Collapse
|
9
|
|
10
|
Valente R, Testi A, Tanfani E, Fato M, Porro I, Santo M, Santori G, Torre G, Ansaldo G. A model to prioritize access to elective surgery on the basis of clinical urgency and waiting time. BMC Health Serv Res 2009; 9:1. [PMID: 19118494 PMCID: PMC2651867 DOI: 10.1186/1472-6963-9-1] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Accepted: 01/01/2009] [Indexed: 11/10/2022] Open
Abstract
Background Prioritization of waiting lists for elective surgery represents a major issue in public systems in view of the fact that patients often suffer from consequences of long waiting times. In addition, administrative and standardized data on waiting lists are generally lacking in Italy, where no detailed national reports are available. This is true although since 2002 the National Government has defined implicit Urgency-Related Groups (URGs) associated with Maximum Time Before Treatment (MTBT), similar to the Australian classification. The aim of this paper is to propose a model to manage waiting lists and prioritize admissions to elective surgery. Methods In 2001, the Italian Ministry of Health funded the Surgical Waiting List Info System (SWALIS) project, with the aim of experimenting solutions for managing elective surgery waiting lists. The project was split into two phases. In the first project phase, ten surgical units in the largest hospital of the Liguria Region were involved in the design of a pre-admission process model. The model was embedded in a Web based software, adopting Italian URGs with minor modifications. The SWALIS pre-admission process was based on the following steps: 1) urgency assessment into URGs; 2) correspondent assignment of a pre-set MTBT; 3) real time prioritization of every referral on the list, according to urgency and waiting time. In the second project phase a prospective descriptive study was performed, when a single general surgery unit was selected as the deployment and test bed, managing all registrations from March 2004 to March 2007 (1809 ordinary and 597 day cases). From August 2005, once the SWALIS model had been modified, waiting lists were monitored and analyzed, measuring the impact of the model by a set of performance indexes (average waiting time, length of the waiting list) and Appropriate Performance Index (API). Results The SWALIS pre-admission model was used for all registrations in the test period, fully covering the case mix of the patients referred to surgery. The software produced real time data and advanced parameters, providing patients and users useful tools to manage waiting lists and to schedule hospital admissions with ease and efficiency. The model protected patients from horizontal and vertical inequities, while positive changes in API were observed in the latest period, meaning that more patients were treated within their MTBT. Conclusion The SWALIS model achieves the purpose of providing useful data to monitor waiting lists appropriately. It allows homogeneous and standardized prioritization, enhancing transparency, efficiency and equity. Due to its applicability, it might represent a pragmatic approach towards surgical waiting lists, useful in both clinical practice and strategic resource management.
Collapse
Affiliation(s)
- Roberto Valente
- Health Management Unit, S. Martino University Hospital, L.go R. Benzi 10, 16132 Genoa, Italy.
| | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Abstract
RATIONALE, AIMS AND OBJECTIVES This paper deals with the problem of surgical waiting lists and is aimed, in particular, at comparing two different prioritization approaches: (1) the clinical assessment of treatment urgency aimed at categorizing patients into urgency-related groups (URGs) with a given recommended maximum waiting time for treatment; and (2) the implementation of an original prioritization scoring algorithm aimed at determining the relative priority of each patient in the waiting list and the corresponding order of admission. METHODS A modelling exercise based on a cohort of 236 patients enrolled on the waiting list of a surgical department in an Italian public university hospital, from 1 January to 30 June 2004, is presented. The comparison is based on a measure called need-adjusted-waiting-days, which allows to take into proper account both urgency and priority. RESULTS The results show that both methods should be implemented simultaneously for increasing the department's performance in terms of both efficiency--outcome gained from a given amount of resources--and equity--how patients are admitted according to their need. CONCLUSIONS Waiting list prioritization should not be limited to classifying patients into URGs, but to using a scoring system as well, in order to schedule patient admissions in an explicit and transparent way.
Collapse
Affiliation(s)
- A Testi
- Department of Economics and Quantitative Methods, University of Genova, Genova, Italy.
| | | | | | | | | |
Collapse
|
12
|
Conner-Spady BL, Johnston GH, Sanmartin C, McGurran JJ, Noseworthy TW. A bird can't fly on one wing: patient views on waiting for hip and knee replacement surgery. Health Expect 2007; 10:108-16. [PMID: 17524004 PMCID: PMC5060392 DOI: 10.1111/j.1369-7625.2006.00425.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To obtain patients' perspectives on acceptable waiting times for hip or knee replacement surgery. METHODS A questionnaire with both open- and close-ended items was mailed to 432 consecutive patients who had hip or knee replacement surgery 3-12 months previously in Saskatchewan, Canada. A content analysis was used to analyse the text data from the open-ended questions. RESULTS The sample of 303 (response rate 70%) was 59% female with a mean age of 70 years (SD 11). The median waiting time from the decision date to surgery was 17 weeks. Individuals who rated their waiting time very acceptable (48%) had a median waiting time of 13 weeks compared with a median waiting time of 22 weeks for those who rated it unacceptable (23%). The two most common determinants of acceptability were patient expectations and pain and its impact on patient quality of life. The median maximum acceptable waiting time was 13 weeks and median ideal waiting time, 8.6 weeks. Seventy-nine per cent felt that those in greater need (higher severity) should go before them on the waiting list. Patient ratings of maximum acceptable waiting time were based on: pain and loss of mobility, time needed to prepare for surgery, and severity at the time of seeing the surgeon. In consideration of changing their surgeon to one with a shorter waiting list, 68% would not. CONCLUSIONS Patient views on waiting times are not only related to quality of life issues, but also to prior expectations and notions of fairness and priority. Understanding patient views on waiting for surgery has implications for better management of waiting times and experiences for joint replacement.
Collapse
Affiliation(s)
- Barbara L Conner-Spady
- Department of Community Health Sciences, University of Calgary, and Western Canada Waiting List Project, Calgary, Alberta, Canada
| | | | | | | | | |
Collapse
|
13
|
Curtis AJ, Wolfe R, Russell COH, Costello AJ, Travis DG, Snow R, McNeil JJ. PRIORITIZING PATIENTS FOR PROSTATECTOMY: BALANCING CLINICAL AND PSYCHOSOCIAL FACTORS. ANZ J Surg 2007; 77:112-7. [PMID: 17305980 DOI: 10.1111/j.1445-2197.2006.03988.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of this study was to develop a points-based approach to prioritize patients for elective transurethral resection of the prostate and to determine the relative contributions that clinical and psychosocial characteristics should make to a measurement of urgency for surgery. Another objective was to measure the agreement between urologists, other medical practitioners and laypersons in assessing the major determinants of priority. METHODS A focus group of urologists and epidemiologists developed a standard questionnaire identifying relevant clinical and psychosocial factors in men with benign prostatic hypertrophy. The questionnaire was used to interview 48 men with benign prostatic hypertrophy being placed on waiting lists for transurethral resection of the prostate at four Victorian public hospitals. Individual patient case vignettes were produced using the answers to the interview questions. Members of an assessor panel comprising six laypeople, six non-urologist medical practitioners, and five urologists individually reviewed the vignettes and assigned urgency ratings and rankings to each patient. The urgency ratings and rankings were used to derive weightings for the clinical and psychosocial factors that were then incorporated into a prioritization tool framework. RESULTS The assessor panel perceived a broad spread of urgency for surgery among the patients. Agreement on rankings and urgency ratings was moderate among assessors. Linear regression showed that the effect of clinical symptoms and psychosocial disturbance held approximately equal-strength independent associations with perceived urgency for all groups of assessors. CONCLUSION Urologists, non-urologist medical practitioners and laypeople considered the severity of benign prostatic hypertrophy symptoms and any resulting psychosocial disturbance as equally important in establishing priority for transurethral resection of the prostate. New prioritization tools should take both into consideration and weight them equally.
Collapse
Affiliation(s)
- Andrea J Curtis
- Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Victoria, Australia.
| | | | | | | | | | | | | |
Collapse
|
14
|
Williams A, Dunning T, Manias E. Continuity of care and general wellbeing of patients with comorbidities requiring joint replacement. J Adv Nurs 2007; 57:244-56. [PMID: 17233645 DOI: 10.1111/j.1365-2648.2006.04093.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM The aim of this paper is to examine the continuity of care and general wellbeing of patients with comorbidities undergoing elective total hip or knee joint replacement. BACKGROUND Advances in medical science and improved lifestyles have reduced mortality rates in most Western countries. As a result, there is an ageing population with a concomitant growth in the number of people who are living with multiple chronic illnesses, commonly referred to as comorbidities. These patients often require acute care services, creating a blend of acute and chronic illness needs. For example, joint replacement surgery is frequently performed to improve impaired mobility associated with osteoarthritis. METHOD A purposive sample of twenty participants with multiple comorbidities who required joint replacement surgery was recruited to obtain survey, interview and medical record audit data. Data were collected during 2004 and 2005. FINDINGS Comorbidity care was poorly co-ordinated prior to having surgery, during the acute care stay and following surgery and primarily entailed prescribed medicines. The main focus in acute care was patient throughput following joint replacement surgery according to a prescribed clinical pathway. General wellbeing was less than optimal: participants reported pain, fatigue, insomnia and alterations in urinary elimination as the chief sources of discomfort during the course of the study. CONCLUSION Continuity of care of comorbidities was lacking. Comorbidities affected patient general wellbeing and delayed recovery from surgery. Acute care, clinical pathways and the specialisation of medicine and nursing subordinated the general problem of patients with comorbidities. Systems designed to integrate and co-ordinate chronic illness care had limited application in the acute care setting. A multidisciplinary, holistic approach is required. Recommendations for further research conclude this paper.
Collapse
Affiliation(s)
- Allison Williams
- School of Nursing, The University of Melbourne, Carlton, Victoria, Australia.
| | | | | |
Collapse
|
15
|
Spigelman AD. Why are we waiting? ANZ J Surg 2003; 73:873. [PMID: 14616555 DOI: 10.1046/j.1445-2197.2003.02847.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
16
|
Affiliation(s)
- Allan D Spigelman
- Faculty of Health University of Newcastle, Hunter Area Health ServiceNew South Wales, Australia
| |
Collapse
|