Rationing healthcare in New Zealand: the use of clinical guidelines

Cataract service redesign in the post-COVID-19 era

COVID-19 pandemic of 2020 has impacted all aspects of clinical practice in the UK. Cataract services suffered severe disruption due to necessary measures taken to reduce elective surgery in order to release capacity to support intensive care requirements. Faced with a potential 50% increase in cataract surgery workload per week in the post-COVID-19 world, eye units should use this event to innovate, not just survive but to also evolve for a sustainable future. In this article, we discuss the inadequacies of existing service rationing options to tackle the COVID-19 cataract backlog. This includes limiting rationing based on visual acuity, limiting surgery to first or only seeing eyes, and postponing clinic and surgical dates according to referral dates. We propose units use the lockdown time to reset and develop a comprehensive patient-centred care pathway using principles of value-based healthcare: the cataract integrated practice units. Developing an agile surgical database that incorporates all aspects of patient need from education to follow-up in their individual cataract journey will allow units to react and plan quickly in the early phase of recovery and beyond. We also discuss the considerations units should bear in mind on telemedicine, modifications for face-to-face clinics, theatre organisation and options of expanding cataract throughput capacity. The pause in elective surgery due to the pandemic may have provided cataract services a rare opportunity to reset and transform cataract service pathways for the digital era.

Equity of access to elective surgery: reflections from NZ clinicians

Objectives

To explore factors potentially influencing equitable access to elective surgery in New Zealand by describing clinicians’ perceptions of equity and the factors they consider when prioritising patients for elective surgery.

Methods

A qualitative study in selected New Zealand localities. A purposive sample of 49 general practitioners, specialists and registrars were interviewed. Data were analysed thematically.

Results

General practitioners described unequal opportunities for patients to access primary and secondary care and, in particular, private sector elective surgery. They felt that socio-economically disadvantaged patients were less able to advocate for themselves and were more vulnerable to being lost to the elective surgical booking system as well as being less able to access private care. Both GPs and secondary care clinicians described situations where they would personally advocate for individual patients to improve their access. Advocacy was related to clinicians’ perceptions of the “value” that patients would receive from the surgery and patients” needs for public sector funding.

Conclusions

The structure of the health system contributes to inequities in access to elective care in New Zealand. Subjective decision making by clinicians has the potential to advantage or disadvantage patients through the weighting clinicians place on socio-demographic factors when making rationing decisions. Review of the potential structural barriers to equitable access, further public debate and guidance for clinicians on the relative importance of socio-demographic factors in deciding access to rationed services are required for allocation of services to be fair.

A knowledge synthesis of patient and public involvement in clinical practice guidelines: study protocol

Background

Failure to reconcile patient preferences and values as well as social norms with clinical practice guidelines (CPGs) recommendations may hamper their implementation in clinical practice. However, little is known about patients and public involvement programs (PPIP) in CPGs development and implementation. This study aims at identifying what it is about PPIP that works, in which contexts are PPIP most likely to be effective, and how are PPIP assumed to lead to better CPGs development and implementation.

Methods and design

A knowledge synthesis will be conducted in four phases. In phase one, literature on PPIP in CPGs development will be searched through bibliographic databases. A call for bibliographic references and unpublished reports will also be sent via the mailing lists of relevant organizations. Eligible publications will include original qualitative, quantitative, or mixed methods study designs reporting on a PPIP pertaining to CPGs development or implementation. They will also include documents produced by CPGs organizations to describe their PPIP. In phase two, grounded in the program's logic model, two independent reviewers will extract data to collect information on the principal components and activities of PPIP, the resources needed, the contexts in which PPIP were developed and tested, and the assumptions underlying PPIP. Quality assessment will be made for all retained publications. Our literature search will be complemented with interviews of key informants drawn from of a purposive sample of CPGs developers and patient/public representatives. In phase three, we will synthesize evidence from both the publications and interviews data using template content analysis to organize the identified components in a meaningful framework of PPIP theories. During a face-to-face workshop, findings will be validated with different stakeholder and a final toolkit for CPGs developers will be refined.

Discussion

The proposed research project will be among the first to explore the PPIP in CPGs development and implementation based on a wide range of publications and key informants interviews. It is anticipated that the results generated by the proposed study will significantly contribute to the improvement of the reconciliation of CPGs with patient preferences and values as well as with social norms.

QUESTIONNAIRE TO AID PRIORITY AND OUTCOMES ASSESSMENT IN GALLSTONE DISEASE

BACKGROUND

Limited health resources necessitate prioritization for access to elective cholecystectomy in New Zealand. We aimed to develop and validate a patient questionnaire for determining the effect of gallstone disease on quality of life (QOL) and evaluate its potential role in appraising prioritization and outcomes from surgery.

METHODS

The Otago gallstones condition-specific questionnaire (CSQ) was designed based on review of published reports, structural equation modelling, input from experts and patient feedback. Fifty-four patients with symptomatic gallstone disease completed the CSQ including a single question asking about global condition impact, along with other QOL measures: the Gallstone Impact Checklist and the Short Form-36 Health Survey. Validity and reliability of the CSQ were assessed using standard psychometric criteria and patient acceptance was explored in a semistructured interview. Patients' priority status for surgery was determined by two participating surgeons and resulting scores were correlated with the QOL measures.

RESULTS

Average CSQ completion time was 2.7 (range 1-5) min and patients found its content concise and comprehensive. Validity was supported through high correlations with the Gallstone Impact Checklist (r = 0.74), the global condition impact (r = 0.69) and related dimensions of the Short Form-36 Health Survey. CSQ questions showed satisfactory internal consistency (Cronbach's alpha = 0.94) and reproducibility (ICC = 0.93, where ICC is intraclass coefficient). Of all the QOL measures, the CSQ was the most clinically relevant, showing the strongest relationship with surgeon-rated priority (r = 0.62).

CONCLUSION

Evidence is provided to support the validity of the CSQ for assessing the effect of gallstone disease on QOL. The CSQ could be particularly valuable in aiding priority decisions surgeons make and may be useful in tracking subsequent outcomes.

Explicit criteria for prioritization of cataract surgery

BACKGROUND

Consensus techniques have been used previously to create explicit criteria to prioritize cataract extraction; however, the appropriateness of the intervention was not included explicitly in previous studies. We developed a prioritization tool for cataract extraction according to the RAND method.

METHODS

Criteria were developed using a modified Delphi panel judgment process. A panel of 11 ophthalmologists was assembled. Ratings were analyzed regarding the level of agreement among panelists. We studied the effect of all variables on the final panel score using general linear and logistic regression models. Priority scoring systems were developed by means of optimal scaling and general linear models. The explicit criteria developed were summarized by means of regression tree analysis.

RESULTS

Eight variables were considered to create the indications. Of the 310 indications that the panel evaluated, 22.6% were considered high priority, 52.3% intermediate priority, and 25.2% low priority. Agreement was reached for 31.9% of the indications and disagreement for 0.3%. Logistic regression and general linear models showed that the preoperative visual acuity of the cataractous eye, visual function, and anticipated visual acuity postoperatively were the most influential variables. Alternative and simple scoring systems were obtained by optimal scaling and general linear models where the previous variables were also the most important. The decision tree also shows the importance of the previous variables and the appropriateness of the intervention.

CONCLUSION

Our results showed acceptable validity as an evaluation and management tool for prioritizing cataract extraction. It also provides easy algorithms for use in clinical practice.

Prioritizing patients for elective surgery: a systematic review

BACKGROUND

Priority scoring tools are moot as means for dealing with burgeoning elective surgical waiting lists. There is ongoing development work in New Zealand, Canada and the UK. This emerging international perspective is invaluable in determining the application of these tools and addressing any pitfalls.

METHODS

A systematic electronic literature review was performed. Information was also retrieved using a search of reference lists of all papers included in the review and contact with those who were involved in the development of such criteria.

RESULTS

The ethical basis of prioritization differed among priority scoring tools and in a number was not stated. The majority of tools covered criteria for specific procedures. Delphi consensus methods and regression were the predominant methods for -deter-mining -specific criteria. Authors' opinions were the main source of generic criteria. Linear and non-linear models or matrices sum-mated criteria.

CONCLUSION

There is debate over the ethical basis for prioritization. It is a concern that it is not addressed in many studies. The development of generic criteria showed a dearth of consensus approaches that represents a significant gap in our knowledge. On the aspects of summation and weighting, the impact of assumptions on the prioritization of patients may not have been fully explored.