Priorización de pacientes en lista de espera para cirugía de cataratas: diferencias en las preferencias entre ciudadanos

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.

Impact of a priority system on patients in waiting lists for knee arthroplasty

RATIONALE, AIMS AND OBJECTIVES

The Agency for Health Quality and Assessment of Catalonia (AQuAS) developed a system for the prioritization of patients on non-urgent waiting lists for cataract as well as knee and hip arthroplasty. The aim was to evaluate the impact of the priority system's application for primary knee arthroplasty (PKA).

METHODS

A retrospective evaluative study with data from the Data Tracking and Management Registry of the CatSalut Waiting Lists for PKA of hospitals in the public hospital network in the period 2003-2009. A description of the characteristics of patients on waiting lists was made and the association between priority scoring and waiting time and the order of operation analysed. Finally, waiting times were simulated that patients would have experienced if being operated on strictly according to a first in first out system or one of priority scoring, to compare them with real waiting times.

RESULTS

The number of people included on waiting lists for PKA was 67403. 67% had a priority score. The distribution of the priority score was negatively skewed with an average score of 70 points. The association with the priority score for the waiting time as well as the order of the operations performed was practically null.

CONCLUSIONS

The study concludes that, globally, the prioritization system for PKA has been implemented but had no effect on the prioritization of patients based on their severity. Nevertheless, in some centres, a moderate correlation between the order of operations performed and the priority score was identified.

[Clinical practice variation in cataract surgery]

PURPOSE

Cataract surgery rates have dramatically increased in the last two decades. However, clinical practice variation in cataract surgery has not been thoroughly studied. The aim of this review is to analyze clinical practice variation, including the causes and consequences of this phenomenon. Then, its role in health care planning and health care quality is focused, emphasizing the importance of reducing it and providing several practical strategies to accomplish it.

RECENT FINDINGS

The latest researches are presented in this article. They identify the development and implementation of clinical practice guidelines as the best tool to standardize care processes.

CONCLUSION

Managing unwarranted or unwanted variation would improve quality of care and may lead to a significant saving in health care spending.

Patient preferences versus physicians' judgement: does it make a difference in healthcare decision making?

Clinicians and public health experts make evidence-based decisions for individual patients, patient groups and even whole populations. In addition to the principles of internal and external validity (evidence), patient preferences must also influence decision making. Great Britain, Australia and Germany are currently discussing methods and procedures for valuing patient preferences in regulatory (authorization and pricing) and in health policy decision making. However, many questions remain on how to best balance patient and public preferences with physicians' judgement in healthcare and health policy decision making. For example, how to define evaluation criteria regarding the perceived value from a patient's perspective? How do physicians' fact-based opinions also reflect patients' preferences based on personal values? Can empirically grounded theories explain differences between patients and experts-and, if so, how? This article aims to identify and compare studies that used different preference elicitation methods and to highlight differences between patient and physician preferences. Therefore, studies comparing patient preferences and physician judgements were analysed in a review. This review shows a limited amount of literature analysing and comparing patient and physician preferences for healthcare interventions and outcomes. Moreover, it shows that methodology used to compare preferences is diverse. A total of 46 studies used the following methods-discrete-choice experiments, conjoint analyses, standard gamble, time trade-offs and paired comparisons-to compare patient preferences with doctor judgements. All studies were published between 1985 and 2011. Most studies reveal a disparity between the preferences of actual patients and those of physicians. For most conditions, physicians underestimated the impact of intervention characteristics on patients' decision making. Differentiated perceptions may reflect ineffective communication between the provider and the patient. This in turn may keep physicians from fully appreciating the impact of certain medical conditions on patient preferences. Because differences exist between physicians' judgement and patient preferences, it is important to incorporate the needs and wants of the patient into treatment decisions.

[Waiting list in general and digestive surgery: patient expectations, quality of life during waiting time and overall satisfaction]

INTRODUCTION

The structural resources of the National Health system are limited, and therefore early surgery cannot be performed on all patients. The objective was to analyse the satisfaction perceived by the patient as regards the delay of treatment by waiting list of three types of surgery. The influence of expectations on waiting times, and impaired quality of life due to the clinical symptoms during the delay, were studied.

MATERIAL AND METHODS

A prospective study was conducted using a postal questionnaire. We compared the expectations (scale of 1 to 5), the impact on quality of life for symptoms (scale of 1 to 5) and the level of patient satisfaction (scale of 1 to 5) with respect to time on the waitng list for cholelithiasis, inguinal hernia and haemorrhoids. The predictors of patient dissatisfaction were analysed.

RESULTS

A total of 57 patients were included. When comparing the characteristics of patients with and without satisfaction over time on the waiting list, days on the waiting list (P=.044), the change in the quality of life due to the symptoms (P=.028), and expectations (P<.001) were significantly different between the two groups. In the multivariate analysis, the expectation was associated with patient dissatisfaction as regards the time on waiting list (OR: 3.14 95% CI: 5.91 to 220.73, P<.001).

CONCLUSIONS

The level of patient dissatisfaction is associated with expectations about time in waiting list.

Comparison of 3 systems for assigning priority to patients on waiting lists for cataract extraction

OBJECTIVE

As the demand for cataract surgery grows, patients in some health care systems are assigned to a waiting list. Several explicit priority tools have been developed. We compared 3 of these: the IRYSS-Cataract Priority Score (ICPS), Catalan Agency for Health Technology Assessment and Research cataract priority system (CCPS), and Western Canada Waiting List project for cataract surgery (WCWL).

DESIGN

Prospective cohort study.

PARTICIPANTS

A total of 1723 consecutive patients awaiting cataract surgery at 5 hospitals.

METHODS

The ICPS, CCPS, and WCWL were applied to these patients after the collection of data. The 3 prioritization systems were compared using correlation methods, 95% limits of agreement, and the kappa coefficient.

RESULTS

Means and standard deviations for the different prioritization systems were 60.9 (22.2) for the ICPS, 35.7 (20.4) for the CCPS, and 25.7 (21.5) for the WCWL. Pearson's correlation coefficients were 0.56 between the ICPS and the CCPS, 0.62 between the WCWL and CCPS, and 0.71 between the ICPS and WCWL. The kappa value among them ranged from 0.13 to 0.40, and the intraclass correlation coefficients ranged from 0.31 to 0.55.

CONCLUSIONS

These 3 prioritization tools showed acceptable correlations but assigned significantly different point scores to similar scenarios. This may have consequences when using these tools for managing a waiting list for cataract extraction.

Potential for 2 priority systems to be used as appropriateness of indication tools for cataract surgery

OBJECTIVE

To test 2 systems developed to prioritize patients on waiting lists for cataract surgery, the Western Canadian Waiting List (WCWL), and the Catalan Agency for Health Technology Assessment and Research Cataract Priority System (CCPS), as tools for judging the appropriateness of the intervention.

DESIGN

Cross-sectional study with follow-up.

PARTICIPANTS

A total of 1723 prospective patients awaiting cataract extraction in 5 hospitals were included in the study.

METHODS

Priority scores using the WCWL and the CCPS systems were calculated and compared with visual acuity (VA) and visual function, measured by the Visual Function-14 index, before and after surgery. The sensitivity of each priority system to different groups was evaluated using a validated appropriateness of indications tool for cataract extraction. One-way analysis of variance and the Jonckheere-Terpstra test were used to detect differences in group scores. Spearman correlation coefficients were also examined.

RESULTS

The WCWL and CCPS systems produced different mean values according to the preoperative levels of VA and visual function (p < 0.0001). Neither system showed a significant difference in mean scores based on gains in VA and visual function. Both systems produced different mean scores according to the different groups of appropriateness set by the appropriateness of indications tool for cataract (p < 0.0001).

CONCLUSIONS

Given that appropriateness tools should correlate with outcomes, we recommend using neither the WCWL nor the CCPS for appropriateness purposes. Incorporating new criteria into these systems may improve the correlation with important outcomes and their adequacy for use as appropriateness tools.

[Planning by service organisation priorities. The process of preparing strategic service-organisation plans]

Strategic planning designs the general setting and the strategic principles of a healthcare system, as well as the general guidelines that govern the development of a health system. Strategic service-organisation plans deal with translating healthcare policies into service policies and respond, principally, to the need for services; these give rise to problems that require a solution. They are developed in line with advances in scientific knowledge, the implementation and current characteristics of the healthcare services and the evolution in the competences of professional teams. There are five stages for their development: identification of health/service requirements; prioritisation of needs in health/services; definition of and agreement on service organisation models (care model and service portfolio); the preparation of and agreement on territorial action plans; introduction and evaluation. A conceptual framework is presented along with practical applications carried out in Catalonia.

Discrete-event simulation applied to analysis of waiting lists. Evaluation of a prioritization system for cataract surgery

OBJECTIVES

To outline the methods used to build a discrete-event simulation model for use in decision-making in the context of waiting list management strategies for cataract surgery by comparing a waiting list prioritization system with the routinely used first-in, first-out (FIFO) discipline.

METHODS

The setting was the Spanish health system. The model reproduced the process of cataract, from incidence of need of surgery (meeting indication criteria), through demand, inclusion on a waiting list, and surgery. "Nonexpressed Need" represented the population that, even with need, would not be included on a waiting list. Parameters were estimated from administrative data and research databases. The impact of introducing a prioritization system on the waiting list compared with the FIFO system was assessed. For all patients entering the waiting list, the main outcome variable was waiting time weighted by priority score. A sensitivity analysis with different scenarios of mean waiting time was used to compare the two alternatives.

RESULTS

The prioritization system shortened waiting time (weighted by priority score) by 1.55 months (95% CI: 1.47 to 1.62) compared with the FIFO system. This difference was statistically significant for all scenarios (which were defined from a waiting time of 4 months to 24 months under the FIFO system). A tendency to greater time savings in scenarios with longer waiting times was observed.

CONCLUSIONS

Discrete-event simulation is useful in decision-making when assessing health services. Introducing a waiting list prioritization system produced greater benefit than allocating surgery by waiting time only. Use of the simulation model would allow the impact of proposed policies to reduce waiting lists or assign resources more efficiently to be tested.

[How should health and healthcare priorities be set and evaluated? Prioritization methods and regional disparities. 2008 SESPAS Report]

The conflict between scarce resources and unlimited needs is perhaps more prominent in the healthcare sector than in any other areas. Thus, setting priorities in health care emerges as an unavoidable task. The laudable aim of adopting any health technology that improves the population's health is impossible when confronted by budgetary constraints. Therefore, the outstanding health problems of a society and the most efficient health technologies in terms of their cost-effectiveness must be identified and patients must be prioritized, bearing in mind aspects of equity and efficiency. The present article reviews the issue of setting health care priorities by examining the experiences that have been put into practice in Spain and abroad. The problem is analyzed at three levels: the "macro" level (strategic planning, identification of higher priority areas and the selection of health care interventions); the "meso" level (incorporation of cost-effectiveness analyses into clinical practice guidelines), and the "micro" level (how to design priority systems for patients on waiting lists based on clinical and social criteria). In all these levels, there is substantial heterogeneity between Spanish regional health services, the steps that need to be taken and the ground that needs to be covered. Thus, we suggest that the first steps that some regional health services have made, together with international initiatives, could serve as a reference for the definitive incorporation of new approaches in priority setting in the Spanish health system as a whole.

Prioritisation of patients on waiting lists for hip and knee arthroplasties and cataract surgery: Instruments validation

Background

Prioritisation instruments were developed for patients on waiting list for hip and knee arthroplasties (AI) and cataract surgery (CI). The aim of the study was to assess their convergent and discriminant validity and inter-observer reliability.

Methods

Multicentre validation study which included orthopaedic surgeons and ophthalmologists from 10 hospitals. Participating doctors were asked to include all eligible patients placed in the waiting list for the procedures under study during the medical visit. Doctors assessed patients' priority through a visual analogue scale (VAS) and administered the prioritisation instrument. Information on socio-demographic data and health-related quality of life (HRQOL) (HUI3, EQ-5D, WOMAC and VF-14) was obtained through a telephone interview with patients. The correlation coefficients between the prioritisation instrument score and VAS and HRQOL were calculated. For the reliability study a self-administered questionnaire, which included hypothetic patients' scenarios, was sent via postal mail to the doctors. The priority of these scenarios was assessed through the prioritisation instrument. The intraclass correlation coefficient (ICC) between doctors was calculated.

Results

Correlations with VAS were strong for the AI (0.64, CI95%: 0.59–0.68) and for the CI (0.65, CI95%: 0.62–0.69), and moderate between the WOMAC and the AI (0.39, CI95%: 0.33–0.45) and the VF-14 and the CI (0.38, IC95%: 0.33–0.43). The results of the discriminant analysis were in general as expected. Inter-observer reliability was 0.79 (CI95%: 0.64–0.94) for the AI, and 0.79 (CI95%: 0.63–0.95) for the CI.

Conclusion

The results show acceptable validity and reliability of the prioritisation instruments in establishing priority for surgery.