Impact of a national system for waitlist prioritization: the experience with NIKE and cataract surgery in Sweden

Ontario Cataract Quality Outcome Initiative: appropriateness and prioritization of cataract surgery

OBJECTIVE

To explore the utility of the Catquest 9SF visual function (VF) questionnaire along with visual acuity (VA) for determining appropriateness and priority for cataract surgery. To evaluate the feasibility of administering the Catquest-9SF in a clinical setting using web-based electronic data capture and interpretation.

DESIGN

Prospective multicentred interventional observational study.

PARTICIPANTS

Subjects undergoing sequential cataract surgery in both eyes at 4 sites in Ontario.

METHODS

We recorded best-corrected VA (BCVA) and VA with current correction (CCVA) in each eye and both eyes (OU) and Catquest-9SF responses on a tablet before and after cataract surgery. Linear regression models were employed to test for associations between VA and visual function (VF).

RESULTS

Preoperative BCVA and CCVA in the worse eye were significant predictors of change in VF (p = 0.006 and p = 0.008, respectively); subjects with worse VA had a greater improvement in VF after surgery. There was a significant association between improvement in VF and improvement in CCVA OU (p = 0.001). Fourteen of 151 subjects (9%) had no improvement or worse VF scores after surgery. Within this group, 10 of 14 subjects had a preoperative score ≤-3, which is suggestive of minimal visual disability. Within this subset, 4 of 14 subjects (2.6%) had a preoperative BCVA of 20/30 or better in their worse eye.

CONCLUSIONS

For patient groups with equal VA, the Catquest-9SF score can help determine priority for surgery. Web-based data capture and interpretation allow for efficient virtual assessments of VF. A BCVA in the worse eye of 20/30 or better combined with a Catquest-9SF score <-3 can be used as a guideline for lowest priority.

Cataract Services in Greek Public Hospitals through and after the Austerity Period

The recent financial crisis caused several problems in the health systems of affected countries like Greece. The present short report highlights several issues regarding the operation of cataract services in Greek public hospitals while certain acts are proposed to cope with recently appeared tight spots. The final aim is to promote relevant discussion in Greece and countries in the region that similar conditions may apply. The cataract service is one of the busiest parts of modern ophthalmology clinics and since they are considered high cost procedures, are affected by limited monetary funding. Institution of a national cataract institute could improve the quality of provided services: To reduce waiting period for a cataract operation, secure safety of procedures and maintain an adequate level of cataract surgeons training.

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.

Barriers and facilitators for implementation of a patient prioritization tool in two specialized rehabilitation programs

INTRODUCTION AND AIMS

Prioritization tools aim to manage access to care by ranking patients equitably in waiting lists based on determined criteria. Patient prioritization has been studied in a wide variety of clinical health services, including rehabilitation contexts. We created a web-based patient prioritization tool (PPT) with the participation of stakeholders in two rehabilitation programs, which we aim to implement into clinical practice. Successful implementation of such innovation can be influenced by a variety of determinants. The goal of this study was to explore facilitators and barriers to the implementation of a PPT in rehabilitation programs.

METHODS

We used two questionnaires and conducted two focus groups among service providers from two rehabilitation programs. We used descriptive statistics to report results of the questionnaires and qualitative content analysis based on the Consolidated Framework for Implementation Research.

RESULTS

Key facilitators are the flexibility and relative advantage of the tool to improve clinical practices and produce beneficial outcomes for patients. Main barriers are the lack of training, financial support and human resources to sustain the implementation process.

CONCLUSION

This is the first study that highlights organizational, individual and innovation levels facilitators and barriers for the implementation of a prioritization tool from service providers' perspective.

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.

A systematic review of patient prioritization tools in non-emergency healthcare services

BACKGROUND

Patient prioritization is a strategy used to manage access to healthcare services. Patient prioritization tools (PPT) contribute to supporting the prioritization decision process, and to its transparency and fairness. Patient prioritization tools can take various forms and are highly dependent on the particular context of application. Consequently, the sets of criteria change from one context to another, especially when used in non-emergency settings. This paper systematically synthesizes and analyzes the published evidence concerning the development and challenges related to the validation and implementation of PPTs in non-emergency settings.

METHODS

We conducted a systematic mixed studies review. We searched evidence in five databases to select articles based on eligibility criteria, and information of included articles was extracted using an extraction grid. The methodological quality of the studies was assessed by using the Mixed Methods Appraisal Tool. The article selection process, data extraction, and quality appraisal were performed by at least two reviewers independently.

RESULTS

We included 48 studies listing 34 different patient prioritization tools. Most of them are designed for managing access to elective surgeries in hospital settings. Two-thirds of the tools were investigated based on reliability or validity. Inconclusive results were found regarding the impact of PPTs on patient waiting times. Advantages associated with PPT use were found mostly in relationship to acceptability of the tools by clinicians and increased transparency and equity for patients.

CONCLUSIONS

This review describes the development and validation processes of PPTs used in non-urgent healthcare settings. Despite the large number of PPTs studied, implementation into clinical practice seems to be an open challenge. Based on the findings of this review, recommendations are proposed to develop, validate, and implement such tools in clinical settings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018107205.

Patients' maximum acceptable waiting time for cataract surgery: a comparison at two time-points 7 years apart

PURPOSE

To evaluate the maximum acceptable waiting time (MAWT) of cataract patients and assess the determinants of their perception of MAWT at two time-points 7 years apart.

METHODS

In 2007 (prior to the transformation of our cataract service to a day case unit) and 2014, 500 consecutive patients with cataract were asked to fill in a preoperative questionnaire addressing their MAWT to undergo cataract surgery. The patients' visual impairment (VF-14 score), education and social status were evaluated.

RESULTS

The mean MAWT was 3.2 months in both periods, whereas the actual waiting time decreased significantly by 1.7 months (p < 0.001). Patients who had self-noted visual impairment were nearly four times (p < 0.001) more likely to accept only an MAWT of <3 months in 2007. In both periods, patients with a VF-14 score lower than the mean were more likely to accept a shorter MAWT (p = 0.002 and p = 0.034). Living together with children or having relatives close by was associated with a greater acceptance of an MAWT longer than 3 months (p = 0.002 and p = 0.023).

CONCLUSION

Reducing the actual mean waiting time had no impact on the mean MAWT. Patients with poor tolerance of waiting had greater self-reported difficulty with vision. Social support was also a strong predictor from the patients' perspective. The VF-14 score had a greater impact than clinical visual acuity (VA) testing. Considering the implementation of standards for waiting lists, objective criteria to guarantee a transparent system should be taken into account.