Prioritization of surgical patients during the COVID-19 pandemic and beyond: A qualitative exploration of patients' perspectives

INTRODUCTION

During the COVID-19 pandemic, prioritizing certain surgical patients became inevitable due to limited surgical capacity. This study aims to identify which factors patients value in priority setting, and to evaluate their perspective on a decision model for surgical prioritization.

METHODS

We enacted a qualitative exploratory study and conducted semi-structured interviews with N = 15 patients. Vignettes were used as guidance. The interviews were transcribed and iteratively analyzed using thematic analysis.

RESULTS

We unraveled three themes: 1) general attitude towards surgical prioritization: patients showed understanding for the difficult decisions to be made, but demanded greater transparency and objectivity; 2) patient-related factors that some participants considered should, or should not, influence the prioritization: age, physical functioning, cognitive functioning, behavior, waiting time, impact on survival and quality of life, emotional consequences, and resource usage; and 3) patients' perspective on a decision model: usage of such a model for prioritization decisions is favorable if the model is simple, uses trustworthy data, and its output is supervised by physicians. The model could also be used as a communication tool to explain prioritization dilemmas to patients.

CONCLUSION

Support for the various factors and use of a decision model varied among patients. Therefore, it seems unrealistic to immediately incorporate these factors in decision models. Instead, this study calls for more research to identify feasible avenues and seek consensus.

Stakeholder Engagement in Designing Attributes for a Discrete Choice Experiment With Policy Implications: An Example of 2 Swiss Studies on Healthcare Delivery

OBJECTIVES

The use of discrete choice experiments (DCEs) has become increasingly popular in health policy development by involving and analyzing the preferences of target groups for different aspects of the policy intervention. In this article, we aim to contribute to the standardization of the process of attribute and attribute level development for DCEs with policy relevance. To do so, we propose and empirically illustrate a framework tool for the development and reporting of attributes and attribute levels, with the systematic engagement of relevant stakeholders.

METHODS

The framework tool was kept general to allow its use as a standard reporting approach on the development process of a DCE, involving relevant stakeholders at each stage. The proposed 3-stage process consists of (1) collection, (2) selection, and (3) refinement of the DCE attributes and attribute levels. The application of the framework tool is illustrated by 2 projects, Health2040 and COCONUTS-both concerning the preferences of the Swiss population for the future organization of healthcare.

RESULTS

By engaging stakeholders, we identified and included attributes and attribute levels that would not have been identified solely through the existing literature. In addition, including multiple stakeholders from different professional backgrounds ensured that the selected attributes and attribute levels were policy relevant, were applicable in practice, and reflected the opinions of multiple actors in healthcare.

CONCLUSION

The proposed framework helps to strengthen the standardization of the reporting on attribute and attribute level development with stakeholder engagement and to guide future research teams designing a DCE with policy implications.

Instruments to assess appropriateness of hip and knee arthroplasty: a systematic review

OBJECTIVE

To assess criteria and psychometric properties of instruments for assessing appropriateness of elective joint arthroplasty (JA) for adults with primary hip and knee osteoarthritis (OA).

METHODS

A systematic review guided by Cochrane methods and PRISMA guidelines. Studies were searched in five databases. Eligible articles include all study designs developing, testing, and/or using an instrument to assess JA appropriateness. Two independent reviewers screened and extracted data. Instruments were compared with Hawker et al. JA consensus criteria. Psychometric properties of instruments were described and appraised guided by Fitzpatrick's and COSMIN approaches.

RESULTS

Of 55 instruments included, none met all Hawker et al. JA consensus criteria. Criteria the most met were pain (n = 50), function (n = 49), quality of life (n = 33), and radiography (n = 24). Criteria the least met were clinical evidence of OA (n = 18), expectations (n = 15), readiness for surgery (n = 11), conservative treatments (n = 8), and patient/surgeon agree benefits outweigh risks (n = 0). Instrument by Arden et al. met the most criteria (6 of 9). The most tested psychometric properties were appropriateness (n = 55), face/content validity (n = 55), predictive validity (n = 29), construct validity and feasibility (n = 24). The least tested psychometric properties were intra-rater reliability (n = 3), internal consistency (n = 5), and inter-rater reliability (n = 13). Instruments by Gutacker et al. and Osborne et al. met the most psychometric properties (4 of 10).

CONCLUSION

Most instruments included traditional criteria for assessing JA appropriateness but did not include a trial of conservative treatments or shared decision-making elements. There was limited evidence on psychometric properties.

Patients’ Prioritization on Surgical Waiting Lists: A Decision Support System

Currently, in Chile, more than a quarter-million of patients are waiting for an elective surgical intervention. This is a worldwide reality, and it occurs as the demand for healthcare is vastly superior to the clinical resources in public systems. Moreover, this phenomenon has worsened due to the COVID-19 sanitary crisis. In order to reduce the impact of this situation, patients in the waiting lists are ranked according to a priority. However, the existing prioritization strategies are not necessarily systematized, and they usually respond only to clinical criteria, excluding other dimensions such as the personal and social context of patients. In this paper, we present a decision-support system designed for the prioritization of surgical waiting lists based on biopsychosocial criteria. The proposed system features three methodological contributions; first, an ad-hoc medical record form that captures the biopsychosocial condition of the patients; second, a dynamic scoring scheme that recognizes that patients’ conditions evolve differently while waiting for the required elective surgery; and third, a methodology for prioritizing and selecting patients based on the corresponding dynamic scores and additional clinical criteria. The designed decision-support system was implemented in the otorhinolaryngology unit in the Hospital of Talca, Chile, in 2018. When compared to the previous prioritization methodology, the results obtained from the use of the system during 2018 and 2019 show that this new methodology outperforms the previous prioritization method quantitatively and qualitatively. As a matter of fact, the designed system allowed a decrease, from 2017 to 2019, in the average number of days in the waiting list from 462 to 282 days.

The SCQ-SCORE: initial validation of a new scoring system for elective stone surgery prioritization in the COVID-19 era

Introduction

Endourology waiting lists have increased during the COVID-19 pandemic and prioritization strategies are needed. Some tiered classifications have been put forward aimed at prioritizing patients by using criteria related with clinical severity or social impact of stone disease, yet no quantitative system has been published to date. The objective of this study is to present a new quantitative scoring system for elective stone surgery prioritization and show its intra- and inter-rater reliability.

Material and methods

A scoring system coined 'SCQ-score' was set up, which consists of 9 variables: infection (ranges 0-3), obstruction (0-3), indwelling time (0-3), admissions (0-3), symptoms (0-2), ureteral location (0-1), solitary or suboptimal kidney (0-1), chronic kidney disease (0-1) and presence of percutaneous nephrostomy (0-1).The intra- and inter-rater reliability of the SCQ-score was prospectively validated in 60 consecutive patients on the waiting list, by calculating the intraclass correlation coefficient (ICC).

Results

The SCQ-score demonstrated having an excellent interobserver agreement (ICC >0.75) for the final score and its different domains. After 4 weeks, a second analysis was carried out to measure its intra-rater reliability, which was also excellent. On average, 134.9 ±50 seconds were required to complete the SCQ-score.

Conclusions

The SCQ-score is a new quantitative system to help prioritize elective stone surgeries, which has been shown to be user-friendly and to have an excellent intra- and inter-rater reliability. Initially developed to help during the COVID-19 pandemic, its utility will probably remain of interest in the post-COVID-19 era to ensure a fairer access to stone surgery.

Prioritization of patients access to outpatient augmentative and alternative communication services in Quebec: a decision tool

Purpose: A large number of people living with a chronic disability wait a long time to access publicly funded rehabilitation services such as Augmentative and Alternative Communication (AAC) services, and there is no standardized tool to prioritize these patients. We aimed to develop a prioritization tool to improve the organization and access to the care for this population.Methods: In this sequential mixed methods study, we began with a qualitative phase in which we conducted semi-structured interviews with 14 stakeholders including patients, their caregivers, and AAC service providers in Quebec City, Canada to gather their ideas about prioritization criteria. Then, during a half-day consensus group meeting with stakeholders, using a consensus-seeking technique (i.e. Technique for Research of Information by Animation of a Group of Experts), we reached consensus on the most important prioritization criteria. These criteria informed the quantitative phase in which used an electronic questionnaire to collect stakeholders' views regarding the relative weights for each of the selected criteria. We analyzed these data using a hybrid quantitative method called group based fuzzy analytical hierarchy process, to obtain the importance weights of the selected eight criteria.Results: Analyses of the interviews revealed 48 criteria. Collectively, the stakeholders reached consensus on eight criteria, and through the electronic questionnaire they defined the selected criteria's importance weights. The selected eight prioritization criteria and their importance weights are: person's safety (weight: 0.274), risks development potential (weight: 0.144), psychological well-being (weight: 0.140), physical well-being (weight: 0.124), life prognosis (weight: 0.106), possible impact on social environment (weight: 0.085), interpersonal relationships (weight: 0.073), and responsibilities and social role (weight: 0.054).Conclusion: In this study, we co-developed a prioritization decision tool with the key stakeholders for prioritization of patients who are referred to AAC services in rehabilitation settings.IMPLICATIONS FOR REHABILIATIONStudies in Canada have shown that people in Canada with a need for rehabilitation services are not receiving publicly available services in a timely manner.There is no standardized tool for the prioritization of AAC patients.In this mixed methods study, we co-developed a prioritization tool with key stakeholders for prioritization of patients who are referred to AAC services in a rehabilitation center in Quebec, Canada.

Patient prioritization tools and their effectiveness in non-emergency healthcare services: a systematic review protocol

BACKGROUND

Waiting lists should be managed as fairly as possible to ensure that patients with greater or more urgent needs receive services first. Patient prioritization refers to the process of ranking referrals in a certain order based on various criteria with the aim of improving fairness and equity in the delivery of care. Despite the widespread use of patient prioritization tools (PPTs) in healthcare services, the existing literature on this subject has mainly focused on emergency settings. Evidence has not been synthesized with respect to all the non-emergency services.

METHODS

This review aims to perform a systematic synthesis of published evidence concerning (1) prioritization tools' characteristics, (2) their metrological properties, and (3) their effect measures across non-emergency services. Five electronic databases will be searched (Cochrane Library, Ovid/MEDLINE, Embase, Web of Science, and CINAHL). Eligibility criteria guiding data selection will be (1) qualitative, quantitative, or mixed methods empirical studies; (2) patient prioritization in any non-emergency setting; and (3) discussing characteristic, metrological properties, or effect measures. Data will be sought to report tool's format, description, population, setting, purpose, criteria, developer, metrological properties, and outcome measures. Two reviewers will independently screen, select, and extract data. Data will be synthesized with sequential exploratory design method. We will use the Mixed Methods Appraisal Tool (MMAT) to assess the quality of articles included in the review.

DISCUSSION

This systematic review will provide much-needed knowledge regarding patient prioritization tools. The results will benefit clinicians, decision-makers, and researchers by giving them a better understanding of the methods used to prioritize patients in clinical settings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018107205.

Prioritizing Zoonotic Diseases: Differences in Perspectives Between Human and Animal Health Professionals in North America

Zoonoses pose a significant burden of illness in North America. Zoonoses represent an additional threat to public health because the natural reservoirs are often animals, particularly wildlife, thus eluding control efforts such as quarantine, vaccination and social distancing. As there are limited resources available, it is necessary to prioritize diseases in order to allocate resources to those posing the greatest public health threat. Many studies have attempted to prioritize zoonoses, but challenges exist. This study uses a quantitative approach, conjoint analysis (CA), to overcome some limitations of traditional disease prioritization exercises. We used CA to conduct a zoonoses prioritization study involving a range of human and animal health professionals across North America; these included epidemiologists, public health practitioners, research scientists, physicians, veterinarians, laboratory technicians and nurses. A total of 699 human health professionals (HHP) and 585 animal health professionals (AHP) participated in this study. We used CA to prioritize 62 zoonotic diseases using 21 criteria. Our findings suggest CA can be used to produce reasonable criteria scores for disease prioritization. The fitted models were satisfactory for both groups with a slightly better fit for AHP compared to HHP (84.4% certainty fit versus 83.6%). Human-related criteria were more influential for HHP in their decision to prioritize zoonoses, while animal-related criteria were more influential for AHP resulting in different disease priority lists. While the differences were not statistically significant, a difference of one or two ranks could be considered important for some individuals. A potential solution to address the varying opinions is discussed. The scientific framework for disease prioritization presented can be revised on a regular basis by updating disease criteria to reflect diseases as they evolve over time; such a framework is of value allowing diseases of highest impact to be identified routinely for resource allocation.

Developing attributes for discrete choice experiments in health: a systematic literature review and case study of alcohol misuse interventions

Discrete choice experiments (DCEs) become increasingly popular to value outcomes for health economic studies and gradually gain acceptance as an input into policy decisions. Developing attributes is a key aspect for the design of DCEs, as their results may misguide decision-makers if they are based on an inappropriate set of attributes. However, the area lacks guidance, and current health-related DCE studies vary considerably in their methods of attribute development, with the consequent danger of providing an unreliable input for policy decisions. The aim of this article is to inform the progress toward a more systematic approach to attribute development for DCE studies in health. A systematic review of the published health-related DCE literature was conducted to lay the foundations for a generic framework which was tested in a case study of alcohol misuse interventions. Four stages of a general attribute development process emerged: (i) raw data collection; (ii) data reduction; (iii) removing inappropriate attributes; and (iv) wording. The case study compared and contrasted a qualitative and mixed-methods approach for the development of attributes for DCEs in the area of alcohol misuse interventions. This article provides a reference point for the design of future DCE experiments in health.

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.

Contributions of Second Opinions, Outcome Forecasts, and Testimonials to Patient Decisions about Knee Replacement Surgery

BACKGROUND

Decision aids are now a well-established means of supporting patients in their medical decision making. The widespread use of decision aids invites questions about how their components contribute to patient decisions.

OBJECTIVE

The objective of this study was to measure the importance of second opinions, patient-specific outcome forecasts, and patient testimonials relative to patient clinical and socioeconomic factors and the primary physician recommendation on the decision to undergo full knee replacement surgery to treat knee osteoarthritis.

METHODS

Middle-aged and older members of the RAND American Life Panel (N = 1616) chose whether to recommend surgery as a treatment for each of 3 hypothetical patients (vignettes) presented in a video-enhanced internet survey. Vignettes randomly sampled levels of scenario attributes.

RESULTS

Second opinions, person-specific outcome forecasts, and 2 consistent patient testimonials strongly affected respondents' decision making; a single testimonial, however, did not significantly affect decisions.

CONCLUSIONS

Information provided in a decision aid, including person-specific outcome forecasts and testimonials, can affect patient choices. The strong effect of testimonials and respondents' interest in reviewing them reinforces concerns about unwanted influence when testimonials are biased.

A quantitative approach to the prioritization of zoonotic diseases in North America: a health professionals' perspective

BACKGROUND

Currently, zoonoses account for 58% to 61% of all communicable diseases causing illness in humans globally and up to 75% of emerging human pathogens. Although the impact of zoonoses on animal health and public health in North America is significant, there has been no published research involving health professionals on the prioritization of zoonoses in this region.

METHODOLOGY/PRINCIPAL FINDINGS

We used conjoint analysis (CA), a well-established quantitative method in market research, to identify the relative importance of 21 key characteristics of zoonotic diseases for their prioritization in Canada and the US. Relative importance weights from the CA were used to develop a point-scoring system to derive a recommended list of zoonoses for prioritization in Canada and the US. Study participants with a background in epidemiology, public health, medical sciences, veterinary sciences and infectious disease research were recruited to complete the online survey (707 from Canada and 764 from the US). Hierarchical Bayes models were fitted to the survey data to derive CA-weighted scores for disease criteria. Scores were applied to 62 zoonotic diseases to rank diseases in order of priority.

CONCLUSIONS/SIGNIFICANCE

We present the first zoonoses prioritization exercise involving health professionals in North America. Our previous study indicated individuals with no prior knowledge in infectious diseases were capable of producing meaningful results with acceptable model fits (79.4%). This study suggests health professionals with some knowledge in infectious diseases were capable of producing meaningful results with better-fitted models than the general public (83.7% and 84.2%). Despite more similarities in demographics and model fit between the combined public and combined professional groups, there was more uniformity across priority lists between the Canadian public and Canadian professionals and between the US public and US professionals. Our study suggests that CA can be used as a potential tool for the prioritization of zoonoses.

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.

Short-term gain for long-term pain? Which patients should be treated and should we ration?

Objectives:

Treatments of common conditions which do not affect mortality often become sidelined in the drive to improve efficiency and reduce costs. The rationing of patients is a divisive but crucial component to universal health care. How should this be accomplished?

Methods and Results:

In this article we examine the outcomes of various rationing methods in varicose veins.

Conclusions:

No method is perfect and treatment of symptoms and complications should remain the target for all physicians.

A quantitative and novel approach to the prioritization of zoonotic diseases in North America: a public perspective

BACKGROUND

Zoonoses account for over half of all communicable diseases causing illness in humans. As there are limited resources available for the control and prevention of zoonotic diseases, a framework for their prioritization is necessary to ensure resources are directed into those of highest importance. Although zoonotic outbreaks are a significant burden of disease in North America, the systematic prioritization of zoonoses in this region has not been previously evaluated.

METHODOLOGY/PRINCIPAL FINDINGS

This study describes the novel use of a well-established quantitative method, conjoint analysis (CA), to identify the relative importance of 21 key characteristics of zoonotic diseases that can be used for their prioritization in Canada and the US. Relative importance weights from the CA were used to develop a point-scoring system to derive a recommended list of zoonoses for prioritization in Canada and the US. Over 1,500 participants from the general public were recruited to complete the online survey (761 from Canada and 778 from the US). Hierarchical Bayes models were fitted to the survey data to derive CA-weighted scores. Scores were applied to 62 zoonotic diseases of public health importance in Canada and the US to rank diseases in order of priority.

CONCLUSIONS/SIGNIFICANCE

This was the first study to describe a systematic and quantitative approach to the prioritization of zoonoses in North America involving public participants. We found individuals with no prior knowledge or experience in prioritizing zoonoses were capable of producing meaningful results using CA as a novel quantitative approach to prioritization. More similarities than differences were observed between countries suggesting general agreement in disease prioritization between Canadians and Americans. We demonstrate CA as a potential tool for the prioritization of zoonoses; other prioritization exercises may also consider this approach.

DEVELOPMENT AND TEST OF A DECISION SUPPORT TOOL FOR HOSPITAL HEALTH TECHNOLOGY ASSESSMENT

Objective: To develop and test a decision-support tool for prioritizing new competing Health Technologies (HTs) after their assessment using the mini-HTA approach.

Methods:A two layer value/risk tool was developed based on the mini-HTA. The first layer included 12 mini-HTA variables classified in two dimensions, namely value (safety, clinical benefit, patient impact, cost-effectiveness, quality of the evidence, innovativeness) and risk (staff, space and process of care impacts, incremental costs, net cost, investment effort). Weights given to these variables were obtained from a survey among decision-makers (at National/Regional level and hospital settings). A second layer included results from mini-HTA (scored as higher, equal or lower), which compares the performance of the new HT (in terms of the abovementioned 12 variables) with the available comparator. An algorithm combining the first (weights) and second (scores) layers was developed to obtain an overall score for each HT, which was then plotted in a value/risk matrix. The tool was tested using results from the mini-HTAs for three new HTs (Surgical Robot, Platelet Rich Plasma, Deep Brain Stimulation).

Results: No significant differences among decision-makers were observed as regards the weights given to the 12 variables, therefore, the median aggregate weights from decision-makers were introduced in the first layer. The dot plot resulting from the mini-HTA presented good power to visually discriminate between the assessed HTs.

Conclusion: The decision-support tool developed here makes possible a robust and straightforward comparison of different competing HTs. This facilitates hospital decision-makers deliberations on the prioritization of competing investments under fixed budgets.

Determining priority for joint replacement: comparing the views of orthopaedic surgeons and other professionals

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.

A stakeholder-informed approach to the identification of criteria for the prioritization of zoonoses in Canada

BACKGROUND

Zoonotic diseases account for over 60% of all communicable diseases causing illness in humans and 75% of recently emerging infectious diseases. As limited resources are available for the control and prevention of zoonotic diseases, it is necessary to prioritize diseases in order to direct resources into those with the greatest needs. The selection of criteria for prioritization has traditionally been on the basis of expert opinion; however, details of the methods used to identify criteria from expert opinion often are not published and a full range of criteria may not be captured by expert opinion.

METHODOLOGY/PRINCIPAL FINDINGS

This study used six focus groups to identify criteria for the prioritization of zoonotic diseases in Canada. Focus groups included people from the public, animal health professionals and human health professionals. A total of 59 criteria were identified for prioritizing zoonotic diseases. Human-related criteria accounted for the highest proportion of criteria identified (55%), followed by animal-related criteria (26%) then pathogen/disease-related criteria (19%). Similarities and differences were observed in the identification and scoring of criteria for disease prioritization between groups; the public groups were strongly influenced by the individual-level of disease burden, the responsibility of the scientific community in disease prioritization and the experiences of recent events while the professional groups were influenced by the societal- and population-level of disease burden and political and public pressure.

CONCLUSIONS/SIGNIFICANCE

This was the first study to describe a mixed semi-quantitative and qualitative approach to deriving criteria for disease prioritization. This was also the first study to involve the opinion of the general public regarding disease prioritization. The number of criteria identified highlights the difficulty in prioritizing zoonotic diseases. The method presented in this paper has formulated a comprehensive list of criteria that can be used to inform future disease prioritization studies.

Stated preferences of physicians and chronic pain sufferers in the use of classic strong opioids

We conducted a two-stage study in France, Germany, Italy, Spain, Sweden, and the United Kingdom of the stated preferences of chronic pain sufferers treated with classic strong opioids and of physicians treating such patients. The qualitative stage identified attributes perceived important through focus groups with 84 pain sufferers and semistructured interviews with 11 physicians. The quantitative stage included online, discrete choice experiments (DCEs) in which respondents chose between hypothetical profiles or an opt-out in 15 choice tasks. The profile descriptions were based on the attributes elicited in the qualitative stage. DCEs were conducted for pain sufferers (N = 242) and physicians (N = 270) who passed a rationality test. Main-effects models were estimated by hierarchical Bayesian regression. Sufferers ranked nausea, pain impact, energy, alertness, and constipation; physicians ranked pain response, central nervous system (CNS) effects, nausea, dose form, and constipation in descending order of importance. Sufferers were unwilling to incur severe side effects to decrease pain and chose the opt-out in approximately one half of the choice tasks, whereas physicians were willing to trade between profiles. The models predicted physicians' choices better than those of pain sufferers. No age, sex, or country effects were seen, but stronger preferences were found among physicians treating noncancer (n = 40) than cancer pain and among the 55% of sufferers who had never discontinued long-term pain medication use. Sufferers' mean pain scores on an 11-point Likert scale were 4.0, 5.7, and 8.6 on their best, average, and worst days, respectively.

Relationship between total hip replacement appropriateness and surgical priority instruments

RATIONALE

Variability in indications for total hip replacement (THR) and unequal waiting times may limit health care access.

OBJECTIVE

To analyse the relationship between appropriateness and previously developed surgical priority instruments.

METHOD

Multicentre cross-validation study of patients placed on the waiting list for THR. Information on surgical priority, surgeons' evaluation of priority through a visual analogue scale (VAS) and health-related quality of life (HRQOL) (Health Utilities Index mark 3, EQ-5D, Western Ontario McMaster Osteoarthritic Index) was collected. THR indications were considered appropriate, uncertain or inappropriate according to appropriateness criteria. Statistical differences and clinically important differences in surgical priority, VAS and HRQOL between appropriateness categories were analysed with the Mann-Whitney U-test and effect size (ES), respectively. Surgical priority score's ability to discriminate appropriate and inappropriate indications was evaluated through the area under the receiver-operating characteristic curve (AUC) and its 95% confidence interval (95% CI).

RESULTS

49.4% (87) of the THR indications were deemed appropriate, 39.8% (70) uncertain and 10.8% (19) inappropriate. Differences in surgical priority score, VAS and HRQOL between appropriateness categories were statistically significant. Clinically important differences were generally small (ES, 0.2-0.5) between inappropriate and uncertain, moderate (ES, 0.5-0.8) between uncertain and appropriate, and large (ES > 0.8) between inappropriate and appropriate categories. The AUC to discriminate appropriate and inappropriate indications was 0.97 (95% CI: 0.96-0.99) and 0.90 (95% CI: 0.83-0.97), respectively.

CONCLUSIONS

The relationship between the surgical priority and appropriateness instruments reinforces their validity and could improve waiting list management by establishing maximum waiting periods based on patients' characteristics.

Different hip and knee priority score systems: are they good for the same thing?

OBJECTIVE

The aim of the present study was to compare two priority tools used for joint replacement for patients on waiting lists, which use two different methods.

METHODS

Two prioritization tools developed and validated by different methodologies were used on the same cohort of patients. The first, an IRYSS hip and knee priority score (IHKPS) developed by RAND method, was applied while patients were on the waiting list. The other, a Catalonia hip-knee priority score (CHKPS) developed by conjoint analysis, was adapted and applied retrospectively. In addition, all patients fulfilled pre-intervention the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Correlation between them was studied by Pearson correlation coefficient (r). Agreement was analysed by means of intra-class correlation coefficient (ICC), Kendall coefficient and Cohern kappa. The relationship between IHKPS, CHKPS and baseline WOMAC scores by r coefficient was studied.

RESULTS

The sample consisted of 774 consecutive patients. Pearson correlation coefficient between IHKPS and CHKPS was 0.79. The agreement study showed that ICC was 0.74, Kendall coefficient 0.86 and kappa 0.66. Finally, correlation between CHKPS and baseline WOMAC ranged from 0.43 to 0.64. The results according to the relationship between IHKPS and WOMAC ranged from 0.50 to 0.74.

CONCLUSIONS

Results support the hypothesis that if the final objective of the prioritization tools is to organize and sort patients on the waiting list, although they use different methodologies, the results are similar.

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.