An Evaluation of Strategies to Reduce Waiting Times for Total Joint Replacement in Ontario

An online individualised patient decision aid improves the quality of decisions in patients considering total knee arthroplasty in routine care: A randomized controlled trial

Objective

The objective of this study was to evaluate the effectiveness of an online patient decision aid with individualised potential outcomes of surgery, on the quality of decisions for knee replacement surgery in routine clinical care.

Design

A pragmatic Randomized Controlled Trial (RCT) in patients considering total knee replacement at a high-volume orthopedic clinic. Patients were randomized at their routine online pre-surgical assessment to either complete a decision aid or not. At their consultation, those in the intervention arm had a surgeon report summarizing the decision aid results. The primary outcome was decision quality, defined as being knowledgeable and choosing the option that matched informed treatment preferences. Multivariate logistic and linear regression analysis was conducted to consider surgeon level clustering and baseline differences between study arms.

Results

Of 163 patients randomized, 155 completed post-surgical surveys and were included in the analysis. The average patient was aged 65 years, obese and had moderate to severe osteoarthritis symptoms at baseline. Patients in the intervention arm had a higher odds of making a quality decision (Odds Ratio ​= ​2.08, 95% CI: 1.08 to 4.02), predominantly through increased knowledge.

Conclusions

This study supports the benefit of a decision aid in combination with a surgeon report to significantly improve decision quality in routine care. While the independent contribution of tailoring the decision aid to patient baseline characteristics and including a surgeon report remains unclear, we demonstrated the feasibility of integrating the decision aid into an online pre-surgical assessment in routine clinical care.

A single-entry model and wait time for hip and knee replacement in eastern health region of Newfoundland and Labrador 2011-2019

BACKGROUND

A single-entry model in healthcare consolidates waiting lists through a central intake and allows patients to see the next available health care provider based on the prioritization. This study aimed to examine whether and to what extent the prioritization reduced wait times for hip and knee replacement surgeries.

METHOD

The survival regression method was used to estimate the effects of priority levels on wait times for consultation and surgery for hip and knee replacements. The sample data included patients who were referred to the Orthopedic Central Intake clinic at the Eastern Health region of Newfoundland and Labrador and had surgery of hip and knee replacements between 2011 and 2019.

RESULT

After adjusting for covariates, the hazard of having consultation booked was greater in patients with priority 1 and 2 than those in priority 3 when and at 90 days after the referral was made for both hip and knee replacements. Regarding wait time for surgery after the decision for surgery was made, while the hazard of having surgery was lower in priority 2 than in priority 3 when and indifferent at 182 days after the decision was made, it was not significantly different between priority 1 and priority 3 among hip replacement patients. Priority levels were not significantly related to the hazard of having surgery for a knee replacement after the decision for surgery was made. Overall, the hazard of having surgery after the referral was made by a primary care physician was greater for patients in high priority than those in low priority. Preferring a specific surgeon indicated at referral was found to delay consultation and it was not significantly related to the total wait time for surgery. Incomplete referral forms prolonged wait time for consultation and patients under age 65 had a longer total wait time than those aged 65 or above.

CONCLUSION

Patients with high priority could have a consultation booked earlier than those with low priority and prioritization in a single entrance model shortens the total wait time for surgery. However, the association between priority levels and wait for surgery after the decision for surgery was made has not well-established.

Effects of a single-entry intake system on access to outpatient visits to specialist physicians and allied health professionals: a systematic review

BACKGROUND

Canada lags behind other countries with respect to wait times for specialist physician and allied health professional consultations. We conducted a systematic review to assess the effects of a single-entry model on waiting time, referral volume and the satisfaction of patients and health care providers.

METHODS

We searched MEDLINE, Embase, Cochrane CENTRAL and CINAHL databases from inception to December 2019. We included studies from countries in the Organisation for Economic Co-operation and Development that reported on the effects of a single-entry model on the time between referral to first assessment by a specialist physician or allied health professional, termed wait time 1 (WT1). Patient volume and the satisfaction of providers and patients were secondary outcomes. We conducted a narrative synthesis using descriptive statistics.

RESULTS

Of the 4637 citations identified, 17 met the eligibility criteria, and we included 10 of these in the final analysis. All of the included studies reported an absolute reduction in WT1 after implementation of the single-entry model. The average percent reduction in WT1 across specialties was greatest for surgical referrals (57%) and urgent internal medicine referrals (40%). Higher initial WT1 was associated with a greater absolute reduction in WT1 after implementation of the single-entry model (p = 0.002). Patient and provider satisfaction with the single-entry model was high in all studies. The effect estimates from all included studies were at high risk of bias.

INTERPRETATION

Single-entry models were associated with an absolute reduction in time from referral from primary care to consultation. These models represent a promising option to improve access to a range of health services, but there is a need for rigorous prospective evaluations to inform policy.

PROSPERO REGISTRATION

CRD42018100395.

Improving the quality of care with a single-entry model of referral for total joint replacement: a preimplementation/postimplementation evaluation

OBJECTIVES

We assessed: (1) waiting time variation among surgeons; (2) proportion of patients receiving surgery within benchmark and (3) influence of the Winnipeg Central Intake Service (WCIS) across five dimensions of quality: accessibility, acceptability, appropriateness, effectiveness, safety.

DESIGN

Preimplementation/postimplementation cross-sectional design comparing historical (n=2282) and prospective (n=2397) cohorts.

SETTING

Regional, provincial health authority.

PARTICIPANTS

Patients awaiting total joint replacement of the hip or knee.

INTERVENTIONS

The WCIS is a single-entry model (SEM) to improve access to total hip replacement (THR) or total knee replacement (TKR) surgery, implemented to minimise variation in total waiting time (TW) across orthopaedic surgeons and increase the proportion of surgeries within 26 weeks (benchmark). Impact of SEMs on quality of care is poorly understood.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes related to 'accessibility': waiting time variation across surgeons, waiting times (Waiting Time 2 (WT2)=decision to treat until surgery and TW=total waiting time) and surgeries within benchmark. Analysis included descriptive statistics, group comparisons and clustered regression.

RESULTS

Variability in TW among surgeons was reduced by 3.7 (hip) and 4.3 (knee) weeks. Mean waiting was reduced for TKR (WT2/TW); TKR within benchmark increased by 5.9%. Accessibility and safety were the only quality dimensions that changed (post-WCIS THR and TKR). Shorter WT2 was associated with post-WCIS (knee), worse Oxford score (hip and knee) and having medical comorbidities (hip). Meeting benchmark was associated with post-WCIS (knee), lower Body Mass Index (BMI) (hip) and worse Oxford score (hip and knee).

CONCLUSIONS

The WCIS reduced variability across surgeon waiting times, with modest reductions in overall waits for surgery. There was improvement in some, but not all, dimensions of quality.

Policy strategies to reduce waiting times for elective surgery: A scoping review and evidence synthesis

OBJECTIVES

The purpose of this evidence-based review is to identify and describe the interventions that have been implemented to reduce waiting times for major elective surgery.

METHODS

Scoping review and presentation of the results according to the SUPPORT tools. We searched MEDLINE/PubMed, Embase, Cochrane Library, SciELO, DARE-HTA, and Google Scholar. The inclusion criteria for research design were comprehensive.

RESULTS

We identified 5200 records. After eliminating duplicates and screening by title and abstract, 171 records remained for full-text assessment, of which 12 were ultimately included for this review because they reported specific interventions and 96 records were included for further reference. The included studies show significant variability regarding elective procedures, population, and type of provider, as well as in the characteristics of the interventions and the settings. All the studies had methodological limitations. We graded the certainty of the evidence as very low.

CONCLUSIONS

According to the evidence found for this review, interventions most likely should be multidimensional, with prioritization strategies on the waiting lists to incorporate equity criteria, together with quality management improvements of the surgical pathways and the use of operating rooms, as well as improvements in the planning of the surgical schedule.

What is the influence of single-entry models on access to elective surgical procedures? A systematic review

BACKGROUND

Single-entry models (SEMs) for the management of patients awaiting elective surgical services are designed to increase access and flow through the system of care. We assessed scope of use and influence of SEMs on access (waiting times/throughput) and patient-centredness (patient/provider acceptability).

METHODS

Systematic review of articles published in 6 relevant electronic databases included studies from database inception to July 2016. Included studies needed to (1) report on the nature of the SEM; (2) specify elective service and (3) address at least 1 of 3 research questions related to (1) scope of use of SEMs; (2) influence on timeliness and access; (3) patient-centredness and acceptability. Article quality was assessed using a modified Downs and Black checklist.

RESULTS

11 studies from Canada, Australia and the UK were included with mostly weak observational design-2 simulations, 5 before-after, 2 descriptive and 2 cross-sectional studies. 9 studies showed a decrease in patient waiting times; 6 showed that more patients were meeting benchmark waiting times; and 5 demonstrated that waiting lists decreased using an SEM as compared with controls. Patient acceptability was examined in 6 studies, with high levels of satisfaction reported. Acceptability among general practitioners/surgeons was mixed, as reported in 1 study. Research varied widely in design, scope, reported outcomes and overall quality.

CONCLUSIONS

This is the first review to assess the influence of SEMs on access to elective surgery for adults. This review demonstrates a potential ability for SEMs to improve timeliness and patient-centredness of elective services; however, the small number of low-quality studies available does not support firm conclusions about the effectiveness of SEMs to improve access. Further evaluation with higher quality designs and rigour is required.

The Community IntraVenous Antibiotic Study (CIVAS): a mixed-methods evaluation of patient preferences for and cost-effectiveness of different service models for delivering outpatient parenteral antimicrobial therapy

Background

Outpatient parenteral antimicrobial therapy (OPAT) is widely used in most developed countries, providing considerable opportunities for improved cost savings. However, it is implemented only partially in the UK, using a variety of service models.

Objectives

The aims of this research were to (1) establish the extent of OPAT service models in England and identify their development; (2) evaluate patients’ preferences for different OPAT service delivery models; (3) assess the cost-effectiveness of different OPAT service delivery models; and (4) convene a consensus panel to consider our evidence and make recommendations.

Methods

This mixed-methods study included seven centres providing OPAT using four main service models: (1) hospital outpatient (HO) attendance; (2) specialist nurse (SN) visiting at home; (3) general nurse (GN) visiting at home; and (4) self-administration (SA) or carer administration. Health-care providers were surveyed and interviewed to explore the implementation of OPAT services in England. OPAT patients were interviewed to determine key service attributes to develop a discrete choice experiment (DCE). This was used to perform a quantitative analysis of their preferences and attitudes. Anonymised OPAT case data were used to model cost-effectiveness with both Markov and simulation modelling methods. An expert panel reviewed the evidence and made recommendations for future service provision and further research.

Results

The systematic review revealed limited robust literature but suggested that HO is least effective and SN is most effective. Qualitative study participants felt that different models of care were suited to different types of patient and they also identified key service attributes. The DCE indicated that type of service was the most important factor, with SN being strongly preferred to HO and SA. Preferences were influenced by attitudes to health care. The results from both Markov and simulation models suggest that a SN model is the optimal service for short treatment courses (up to 7 days). Net monetary benefit (NMB) values for HO, GN and SN services were £2493, £2547 and £2655, respectively. For longer treatment, SA appears to be optimal, although SNs provide slightly higher benefits at increased cost. NMB values for HO, GN, SN and SA services were £8240, £9550, £10,388 and £10,644, respectively. The simulation model provided useful information for planning OPAT services. The expert panel requested more guidance for service providers and commissioners. Overall, they agreed that mixed service models were preferable.

Limitations

Recruitment to the qualitative study was suboptimal in the very elderly and ethnic minorities, so the preferences of patients from these groups might not be represented. The study recruited from Yorkshire, so the findings may not be applicable nationally.

Conclusions

The quantitative preference analysis and economic modelling favoured a SN model, although there are differences between sociodemographic groups. SA provides cost savings for long-term treatment but is not appropriate for all.

Future work

Further research is necessary to replicate our results in other regions and populations and to evaluate mixed service models. The simulation modelling and DCE methods used here may be applicable in other health-care settings.

Funding

The National Institute for Health Research Health Service and Delivery Research programme.

Applying dynamic simulation modeling methods in health care delivery research-the SIMULATE checklist: report of the ISPOR simulation modeling emerging good practices task force

Health care delivery systems are inherently complex, consisting of multiple tiers of interdependent subsystems and processes that are adaptive to changes in the environment and behave in a nonlinear fashion. Traditional health technology assessment and modeling methods often neglect the wider health system impacts that can be critical for achieving desired health system goals and are often of limited usefulness when applied to complex health systems. Researchers and health care decision makers can either underestimate or fail to consider the interactions among the people, processes, technology, and facility designs. Health care delivery system interventions need to incorporate the dynamics and complexities of the health care system context in which the intervention is delivered. This report provides an overview of common dynamic simulation modeling methods and examples of health care system interventions in which such methods could be useful. Three dynamic simulation modeling methods are presented to evaluate system interventions for health care delivery: system dynamics, discrete event simulation, and agent-based modeling. In contrast to conventional evaluations, a dynamic systems approach incorporates the complexity of the system and anticipates the upstream and downstream consequences of changes in complex health care delivery systems. This report assists researchers and decision makers in deciding whether these simulation methods are appropriate to address specific health system problems through an eight-point checklist referred to as the SIMULATE (System, Interactions, Multilevel, Understanding, Loops, Agents, Time, Emergence) tool. It is a primer for researchers and decision makers working in health care delivery and implementation sciences who face complex challenges in delivering effective and efficient care that can be addressed with system interventions. On reviewing this report, the readers should be able to identify whether these simulation modeling methods are appropriate to answer the problem they are addressing and to recognize the differences of these methods from other modeling approaches used typically in health technology assessment applications.

Indications for hip and knee replacement in Sweden

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.

Patient choice systems and waiting times for scheduled services

Access to scheduled healthcare is a continuing challenge. A synthesis of the international literature was conducted to examine the potential of patient choice systems to reduce waiting times in Canada. A multitude of factors appear to influence the actions and outcomes of patients, providers, and systems. For choice systems to be effective, there must be uptake, which requires incentives and supports. Choice should be considered as but one element of a comprehensive waiting time management strategy.