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Pacheco-Brousseau L, Stacey D, Desmeules F, Ben Amor S, Lambert D, Tanguay E, Hillaby A, Bechiau C, Charette M, Poitras S. Instruments to assess appropriateness of hip and knee arthroplasty: a systematic review. Osteoarthritis Cartilage 2023:S1063-4584(23)00701-X. [PMID: 36898655 DOI: 10.1016/j.joca.2023.02.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 03/12/2023]
Abstract
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.
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Affiliation(s)
- L Pacheco-Brousseau
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada.
| | - D Stacey
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Canada.
| | - F Desmeules
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, Canada; Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Montréal, Canada.
| | - S Ben Amor
- Telfer School of Management, University of Ottawa, Ottawa, Canada.
| | - D Lambert
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada.
| | - E Tanguay
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada.
| | - A Hillaby
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada.
| | - C Bechiau
- School of Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Canada.
| | - M Charette
- Population Health, Interdisciplinary School of Health Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada.
| | - S Poitras
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada.
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2
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A novel multi-criteria decision-making approach for prioritization of elective surgeries through formulation of “weighted MeNTS scoring system”. Heliyon 2022; 8:e10339. [PMID: 36090224 PMCID: PMC9449563 DOI: 10.1016/j.heliyon.2022.e10339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 06/30/2022] [Accepted: 08/12/2022] [Indexed: 11/22/2022] Open
Abstract
Background Publicly funded healthcare system has long non-manageable elective surgery waiting lists due to the non-existence of systematic mathematical modelling that can assess the relative priority of patients on elective surgery waiting lists thus denying the provision of surgical support to the patients with higher urgency. Mostly the patients of general surgery are entertain with highly subjective “time-honoured” methods that are inadequate to measure and compare the urgency of surgical procedure. Objective A methodology of assigning priorities to patients on elective surgery waiting lists has been presented in this paper using weighted criteria objectives. The objectives hve been chosen and assigned weights based on hospital conditions, and in consultation with the surgeons in hospital in Pakistan. Methods The proposed methodology presents two working contributions; first, a scoring mechanism based on MeNTS scoring system with weighted criterion that objectively translate the condition of patient prior to the surgical procedure; and second, a patient prioritization methodology to select patients for surgeries according to the corresponding scores. Detailed simulation results from actual patient data have been presented to evaluate the effectiveness of the proposed methodology, and its applicability and ease of use has been tested in real-time by surgeons while providing consultations to their patients. Results The proposed methodology outperforms the traditional “first-come-first-serve” methodology as there was a 30% reduction in average waiting time in elective surgery waiting lists (from 4.246 to 2.956 days) with 103 (90%) of patients being entertained before or within the unprioritized surgeries time span, with 94 patients having surgery within 1 day of being on waiting list (an increase of 47 patients). Moreover, transparency and equity were also found in the adaptation of this strategy to prioritize the elective surgery patients. Conclusions Prioritizing patients on elective surgery waiting lists is an important concern in surgical field. In most of the methodologies presented in earlier research, prioritization of patients for surgery is carried out subjectively. This study shows that the proposed technique has the potential to decrease the waiting times for patients on elective surgery waiting lists, as well as be presented as an objective methodology for preparing the elective surgery waiting lists to increase the transparency in waiting list.
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3
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Breton M, Smithman MA, Kreindler SA, Jbilou J, Wong ST, Gard Marshall E, Sasseville M, Sutherland JM, Crooks VA, Shaw J, Contandriopoulos D, Brousselle A, Green M. Designing centralized waiting lists for attachment to a primary care provider: Considerations from a logic analysis. EVALUATION AND PROGRAM PLANNING 2021; 89:101962. [PMID: 34127272 DOI: 10.1016/j.evalprogplan.2021.101962] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 04/22/2021] [Accepted: 05/08/2021] [Indexed: 06/12/2023]
Abstract
Access to a regular primary care provider is essential to quality care. In Canada, where 15 % of patients are unattached (i.e., without a regular provider), centralized waiting lists (CWLs) help attach patients to a primary care provider (family physician or nurse practitioner). Previous studies reveal mechanisms needed for CWLs to work, but focus mostly on CWLs for specialized health care. We aim to better understand how to design CWLs for unattached patients in primary care. In this study, a logic analysis compares empirical evidence from a qualitative case study of CWLs for unattached patients in seven Canadian provinces to programme theory derived from a realist review on CWLs. Data is analyzed using context-intervention-mechanism-outcome configurations. Results identify mechanisms involved in three components of CWL design: patient registration, patient prioritization, and patient assignment to a provider for attachment. CWL programme theory is revised to integrate mechanisms specific to primary care, where patients, rather than referring providers, are responsible for registering on the CWL, where prioritization must consider a broad range of conditions and characteristics, and where long-term acceptability of attachment is important. The study provides new insight into mechanisms that enable CWLs for unattached patients to work.
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Affiliation(s)
- Mylaine Breton
- Department of Community Health Sciences, Université de Sherbrooke, Canadian Research Chair in Clinical Governance on Primary Health Care, Longueuil, QC, Canada
| | | | - Sara A Kreindler
- Department of Community Health Sciences, Manitoba Research Chair in Health System Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Jalila Jbilou
- Centre de formation médicale du Nouveau-Brunswick and École de psychologie, Université de Moncton, Moncton, NB, Canada
| | - Sabrina T Wong
- School of Nursing and Centre for Health Services and Policy Research, University of British Columbia, BC Primary Care Sentinel Surveillance Network, Vancouver, BC, Canada
| | | | | | - Jason M Sutherland
- Centre for Health Services and Policy Research, University of British Columbia, Michael Smith Foundation for Health Research, Vancouver, BC, Canada
| | - Valorie A Crooks
- Department of Geography, Simon Fraser University, Michael Smith Foundation for Health Research, Canada Research Chair in Health Service Geographies, Burnaby, BC, Canada
| | - Jay Shaw
- Institute for Health System Solutions and Virtual Care, Women's College Research Institute, Women's College Hospital, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Damien Contandriopoulos
- School of Nursing, University of Victoria, Research Chair Policies, Knowledge and Health (Pocosa/Politiques, Connaissances, Santé), Victoria, BC, Canada
| | - Astrid Brousselle
- School of Public Administration, University of Victoria, Victoria, BC, Canada
| | - Michael Green
- Departments of Family Medicine and Public Health Sciences, Queen's University, CTAQ Chair in Applied Health Economics/Health Policy, Centre for Health Services and Policy Research, Centre for Studies in Primary Care, Institute for Clinical Evaluative Sciences, Kingston, ON, Canada
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Lungu DA, Foresi E, Belardi P, Nuti S, Giannini A, Simoncini T. The Impact of New Surgical Techniques on Geographical Unwarranted Variation: The Case of Benign Hysterectomy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18136722. [PMID: 34206452 PMCID: PMC8297008 DOI: 10.3390/ijerph18136722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/18/2021] [Accepted: 06/19/2021] [Indexed: 11/16/2022]
Abstract
Since the 1980s, the international literature has reported variations for healthcare services, especially for elective ones. Variations are positive if they reflect patient preferences, while if they do not, they are unwarranted, and thus avoidable. Benign hysterectomy is among the most frequent elective surgical procedures in developed countries, and, in recent years, it has been increasingly delivered through minimally invasive surgical techniques, namely laparoscopic or robotic. The question therefore arises over what the impact of these new surgical techniques on avoidable variation is. In this study we analyze the extent of unwarranted geographical variation of treatment rates and of the adoption of minimally invasive procedures for benign hysterectomy in an Italian regional healthcare system. We assess the impact of the surgical approach on the provision of benign hysterectomy, in terms of efficiency (by measuring the average length of stay) and efficacy (by measuring the post-operative complications). Geographical variation was observed among regional health districts for treatment rates and waiting times. At a provider level, we found differences for the minimally invasive approach. We found a positive and significant association between rates and the percentage of minimally invasive procedures. Providers that frequently adopt minimally invasive procedures have shorter average length of stay, and when they also perform open hysterectomies, fewer complications.
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Affiliation(s)
- Daniel Adrian Lungu
- Management and Healthcare Laboratory, Institute of Management and Department EMbeDS, Scuola Superiore Sant’Anna, 56127 Pisa, Italy; (E.F.); (P.B.); (S.N.)
- Correspondence:
| | - Elisa Foresi
- Management and Healthcare Laboratory, Institute of Management and Department EMbeDS, Scuola Superiore Sant’Anna, 56127 Pisa, Italy; (E.F.); (P.B.); (S.N.)
| | - Paolo Belardi
- Management and Healthcare Laboratory, Institute of Management and Department EMbeDS, Scuola Superiore Sant’Anna, 56127 Pisa, Italy; (E.F.); (P.B.); (S.N.)
| | - Sabina Nuti
- Management and Healthcare Laboratory, Institute of Management and Department EMbeDS, Scuola Superiore Sant’Anna, 56127 Pisa, Italy; (E.F.); (P.B.); (S.N.)
| | - Andrea Giannini
- Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (A.G.); (T.S.)
| | - Tommaso Simoncini
- Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (A.G.); (T.S.)
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5
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Barriers and facilitators for implementation of a patient prioritization tool in two specialized rehabilitation programs. JBI Evid Implement 2021; 19:149-161. [PMID: 33843768 DOI: 10.1097/xeb.0000000000000281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Déry J, Ruiz A, Routhier F, Bélanger V, Côté A, Ait-Kadi D, Gagnon MP, Deslauriers S, Lopes Pecora AT, Redondo E, Allaire AS, Lamontagne ME. A systematic review of patient prioritization tools in non-emergency healthcare services. Syst Rev 2020; 9:227. [PMID: 33023666 PMCID: PMC7541289 DOI: 10.1186/s13643-020-01482-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/17/2020] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Julien Déry
- Department of Rehabilitation, Université Laval, Québec, Canada.,Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec, Canada
| | - Angel Ruiz
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec, Canada.,Faculty of Business Administration, Université Laval, Québec, Canada.,Centre interuniversitaire de recherche sur les réseaux d'entreprise, la logistique et le transport (CIRRELT), Université de Montréal, Montréal, Canada
| | - François Routhier
- Department of Rehabilitation, Université Laval, Québec, Canada.,Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec, Canada
| | - Valérie Bélanger
- Centre interuniversitaire de recherche sur les réseaux d'entreprise, la logistique et le transport (CIRRELT), Université de Montréal, Montréal, Canada.,Department of Logistics and Operations Management, HEC Montréal, Montréal, Canada
| | - André Côté
- Faculty of Business Administration, Université Laval, Québec, Canada.,Centre de recherche du CHU de Québec, Université Laval, Québec, Canada.,Centre de recherche en gestion des services de santé, Université Laval, Québec, Canada
| | - Daoud Ait-Kadi
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec, Canada.,Centre interuniversitaire de recherche sur les réseaux d'entreprise, la logistique et le transport (CIRRELT), Université de Montréal, Montréal, Canada.,Department of Mechanical Engineering, Université Laval, Québec, Canada
| | - Marie-Pierre Gagnon
- Centre de recherche du CHU de Québec, Université Laval, Québec, Canada.,Faculty of Nursing, Université Laval, Québec, Canada
| | - Simon Deslauriers
- Department of Rehabilitation, Université Laval, Québec, Canada.,Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec, Canada
| | - Ana Tereza Lopes Pecora
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec, Canada
| | - Eduardo Redondo
- Faculty of Business Administration, Université Laval, Québec, Canada.,Centre interuniversitaire de recherche sur les réseaux d'entreprise, la logistique et le transport (CIRRELT), Université de Montréal, Montréal, Canada
| | - Anne-Sophie Allaire
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec, Canada
| | - Marie-Eve Lamontagne
- Department of Rehabilitation, Université Laval, Québec, Canada. .,Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec, Canada.
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Srikumar G, Eglinton T, MacCormick AD. Development of the General surgery prioritisation tool implemented in New Zealand in 2018. Health Policy 2020; 124:1043-1049. [DOI: 10.1016/j.healthpol.2020.07.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 07/05/2020] [Accepted: 07/10/2020] [Indexed: 11/25/2022]
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8
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Breton M, Smithman MA, Sasseville M, Kreindler SA, Sutherland JM, Beauséjour M, Green M, Marshall EG, Jbilou J, Shaw J, Brousselle A, Contandriopoulos D, Crooks VA, Wong ST. How the design and implementation of centralized waiting lists influence their use and effect on access to healthcare - A realist review. Health Policy 2020; 124:787-795. [PMID: 32553740 DOI: 10.1016/j.healthpol.2020.05.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 05/02/2020] [Accepted: 05/19/2020] [Indexed: 12/11/2022]
Abstract
CONTEXT Many health systems have centralized waiting lists (CWLs), but there is limited evidence on CWL effectiveness and how to design and implement them. AIM To understand how CWLs' design and implementation influence their use and effect on access to healthcare. METHODS We conducted a realist review (n = 21 articles), extracting context-intervention-mechanism-outcome configurations to identify demi-regularities (i.e., recurring patterns of how CWLs work). RESULTS In implementing non-mandatory CWLs, acceptability to providers influences their uptake of the CWL. CWL eligibility criteria that are unclear or conflict with providers' role or judgement may result in inequities in patient registration. In CWLs that prioritize patients, providers must perceive the criteria as clear and appropriate to assess patients' level of need; otherwise, prioritization may be inconsistent. During patients' assignment to service providers, providers may select less-complex patients to obtain CWLs rewards or avoid penalties; or may select patients for other policies with stronger incentives, disregarding the established patient order and leading to inequities and limited effectiveness. CONCLUSION These findings highlight the need to consider provider behaviours in the four sequential CWL design components: CWL implementation, patient registration, patient prioritization and patient assignment to providers. Otherwise, CWLs may result in limited effects on access or lead to inequities in access to services.
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Affiliation(s)
- Mylaine Breton
- Department of Community Health Sciences, Université de Sherbrooke, Canadian Research Chair in Clinical Governance on Primary Health Care, Longueuil, QC, Canada.
| | | | - Martin Sasseville
- Centre de recherche Charles-Le Moyne - Saguenay-Lac-Saint-Jean sur les innovations en santé - Université de Sherbrooke, Longueuil, QC, Canada
| | - Sara A Kreindler
- Department of Community Health Sciences, and Manitoba Research Chair in Health System Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Jason M Sutherland
- Centre for Health Services and Policy Research, University of British Columbia, Michael Smith Foundation for Health Research, Vancouver, BC, Canada
| | - Marie Beauséjour
- Department of Community Health Sciences, Université de Sherbrooke, Longueuil, QC, Canada
| | - Michael Green
- Departments of Family Medicine and Public Health Sciences, Queen's University, Centre for Health Services and Policy Research, Centre for Studies in Primary Care, Institute for Clinical Evaluative Sciences, Kingston, ON, Canada
| | | | - Jalila Jbilou
- Centre de formation médicale du Nouveau-Brunswick and École de psychologie, Université de Moncton, Moncton, NB, Canada
| | - Jay Shaw
- Institute for Health System Solutions and Virtual Care, Women's College Research Institute, Women's College Hospital, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Astrid Brousselle
- School of Public Administration, University of Victoria, Victoria, BC, Canada
| | - Damien Contandriopoulos
- School of Nursing, University of Victoria, Research Chair Policies, Knowledge and Health (Pocosa/Politiques, Connaissances, Santé), Victoria, BC, Canada
| | - Valorie A Crooks
- Department of Geography, Simon Fraser University, Michael Smith Foundation for Health Research, Canada Research Chair in Health Service Geographies, Burnaby, BC, Canada
| | - Sabrina T Wong
- School of Nursing and Centre for Health Services and Policy Research, University of British Columbia, BC Primary Care Sentinel Surveillance Network, Vancouver, BC, Canada
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Abstract
AIM The aim of this study was to investigate whether racial disparities in healthcare exist within a New Zealand pediatric surgical outreach service in a high indigenous Māori population. METHODOLOGY This retrospective study assessed all pediatric surgical procedures performed within a secondary center in New Zealand between May 2014 and May 2016. The days between the date of surgery booking on the waiting list and actual date of surgery were calculated and compared to their corresponding elective surgery waiting target times set by the New Zealand Ministry of Health (MoH). Patient demographic data were collated to then identify any discrepancy between ethnic groups. RESULTS A total of 203 pediatric surgical procedures were performed on 193 patients. Of the 194 (95%) procedures that were included in the study, 30 breached a maximum waiting time. Though this represented a small proportion of patients, Māori were significantly over represented in this group. CONCLUSION The majority of our patients with delayed elective surgery were of Māori ethnicity, for reasons not entirely accounted for by common socioeconomic determinants of health. Our study suggests the possibility of innate systemic causes not detected by standard models of health. However, further research with larger cohorts is needed. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Canaan Aumua
- Waikato District Health Board, Department of Pediatric Surgery, New Zealand; University of Auckland, New Zealand
| | | | - Udaya Samarakkody
- Waikato District Health Board, Department of Pediatric Surgery, New Zealand; University of Auckland, New Zealand; Lakes District Health Board, Department of Pediatrics, New Zealand.
| | - Danny de Lore
- Waikato District Health Board, Department of Pediatric Surgery, New Zealand; Lakes District Health Board, Department of Pediatrics, New Zealand
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10
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McLeod D, Dew K, Morgan S, Dowell A, Cumming J, Cormack D, McKinlay E, Love T. Equity of access to elective surgery: reflections from NZ clinicians. J Health Serv Res Policy 2016; 9 Suppl 2:41-7. [PMID: 15511325 DOI: 10.1258/1355819042349916] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Deborah McLeod
- Department of General Practice, Wellington School of Medicine, University of Otago, PO Box 7343, Wellington South, New Zealand
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Leov J, Barrett E, Gallagher S, Swain N. A qualitative study of pain experiences in patients requiring hip and knee arthroplasty. J Health Psychol 2016; 22:186-196. [DOI: 10.1177/1359105315597054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The aim of this study was to conduct an in-depth investigation of experiences with pain before knee and hip replacement surgery. A total of 20 patients were interviewed, and interpretative phenomenological analysis was used to identify themes. These were as follows: living with pain, pain conceptualised, pain treatments and healthcare system. Pre-surgical pain is very disabling and is viewed as biological. There was an associated loss of independence. Pharmaceutical management is used by all but not entirely effective, psychological therapies are underutilised. Patients were frustrated, angry, and confused about qualifying for surgery. Many areas of care could be improved to help these pre-surgical patients.
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12
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Ball SL, Greenhalgh J, Roland M. Referral management centres as a means of reducing outpatients attendances: how do they work and what influences successful implementation and perceived effectiveness? BMC FAMILY PRACTICE 2016; 17:37. [PMID: 27009255 PMCID: PMC4806456 DOI: 10.1186/s12875-016-0434-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 03/16/2016] [Indexed: 12/03/2022]
Abstract
Background The rising volume of referrals to secondary care is a continuing concern in the NHS in England, with considerable resource implications. Referral management centres (RMCs) are one of a range of initiatives brought in to curtail this rise, but there is currently limited evidence for their effectiveness, and little is known about their mechanisms of action. This study aimed to gain a better understanding of how RMCs operate and the factors contributing to the achievement of their goals. Drawing on the principles of realist evaluation, we sought to elicit programme theories (the ideas and assumptions about how a programme works) and to identify the key issues to be considered when establishing or evaluating such schemes. Methods Qualitative study with a purposive sample of health professionals and managers involved in the commissioning, set-up and running of four referral management centres in England and with GPs referring through these centres. Semi-structured interviews were conducted with 18 participants. Interviews were audio-recorded and transcribed. Data were analysed thematically. Results Interview data highlighted the diverse aims and functions of RMCs, reflecting a range of underlying programme theories. These included the overarching theory that RMCs work by ensuring the best use of limited resources and three sub-theories, relating to how this could be achieved, namely, improving the quality of referrals and patient care, reducing referrals, and increasing efficiency in the referral process. The aims of the schemes, however, varied between sites and between stakeholders, and evolved significantly over time. Three themes were identified relating to the context in which RMCs were implemented and managed: the impact of practical and administrative difficulties; the importance and challenge of stakeholder buy-in; and the dependence of perceived effectiveness on the aims and priorities of the scheme. Many RMCs were described as successful by those involved, despite limited evidence of reduced referrals or cost-savings. Conclusions The findings of this study have a number of implications for the development of similar schemes, with respect to the need to ensure clarity of aims and to identify indicators of success from the outset, to anticipate scheme evolution and plan for potential changes with respect to IT systems and referral processes. Also identified, is the need for further research that evaluates the effectiveness and cost effectiveness of particular models of RMC.
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Affiliation(s)
- Sarah L Ball
- RAND Europe, Westbrook Centre, Milton Road, Cambridge, CB4 1YG, UK.
| | - Joanne Greenhalgh
- School of Sociology and Social Policy, University of Leeds, LEEDS, LS2 9JT, UK
| | - Martin Roland
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge School of Clinical Medicine, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK
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Derrett S, Cousins K, Gauld R. A messy reality: an analysis of New Zealand's elective surgery scoring system via media sources, 2000-2006. Int J Health Plann Manage 2012; 28:48-62. [PMID: 22815091 PMCID: PMC3617466 DOI: 10.1002/hpm.2127] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Waiting lists for elective procedures are a characteristic feature of tax-funded universal health systems. New Zealand has gained a reputation for its 'booking system' for waiting list management, introduced in the early-1990s. The New Zealand system uses criteria to 'score' and then 'book' qualifying patients for surgery. This article aims to (i) describe key issues focused on by the media, (ii) identify local strategies and (iii) present evidence of variation. Newspaper sources were searched (2000-2006). A total of 1199 booking system stories were identified. Findings demonstrate, from a national system perspective, the extraordinarily difficult nature of maintaining overall control and coordination. Equity and national consistency are affected when hospitals respond to local pressure by reducing access to elective treatment. Findings suggest that central government probably needs to be closely involved in local-level management and policy adjustments; that through the study period, the New Zealand system appears to have been largely out of the control of government; and that governments elsewhere may need to be cautious when considering developing similar systems. Developing and implementing scoring and booking systems may always be a 'messy reality' with unintended consequences and throwing regional differences in service management and access into stark relief.
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Affiliation(s)
- Sarah Derrett
- Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
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Dew K, Stubbe M, Macdonald L, Dowell A, Plumridge E. The (non) use of prioritisation protocols by surgeons. SOCIOLOGY OF HEALTH & ILLNESS 2010; 32:545-562. [PMID: 20163563 DOI: 10.1111/j.1467-9566.2009.01229.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Priority setting and rationing is a dominant feature of contemporary health policy. In New Zealand, clinical priority assessment criteria (CPAC) tools have been developed to make access to elective surgery more equitable and efficient. Research was undertaken to identify how surgeons used these tools in the consultation. Forty-seven consultations with 15 different surgeons have to date been video- and audio-recorded. There were no instances where CPAC tools were explicitly used in the consultation. Drawing on the methodology of conversation analysis and the concept of news delivery as developed by Maynard, this paper argues that the delivery of diagnoses and treatment plans can usefully be seen in part as the delivery of bad or good news. Using three case studies to illustrate the argument, it is suggested that the interactional work required in the delivery of such news challenges the ability of clinicians to use protocols such as CPAC. The analysis sheds light on important consultation processes that need to be more carefully considered when designing interventions to influence clinician behaviour. In order to influence the behaviour of clinicians to achieve policy goals, greater attention needs to be paid to the interactional demands of the consultation process.
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Affiliation(s)
- Kevin Dew
- Sociology Programme, Victoria University of Wellington, Wellington 6140, New Zealand.
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15
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Hudak PL, Grassau P, Glazier RH, Hawker G, Kreder H, Coyte P, Mahomed N, Wright JG. ``Not Everyone Who Needs One Is Going to Get One'': The Influence of Medical Brokering on Patient Candidacy for Total Joint Arthroplasty. Med Decis Making 2008; 28:773-80. [DOI: 10.1177/0272989x08318468] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Many patients in Ontario, despite being appropriate candidates for total joint arthroplasty (TJA), are not offered surgery. To understand this discrepancy, the authors sought to explore the process by which physicians determine patient candidacy for TJA. Methods. Six focus groups (2 each of orthopedic surgeons, of rheumatologists, and of family physicians) and subsequent in-depth interviews were conducted with 50 practicing clinicians in Ontario. Results. Health care system constraints, including extensive waiting lists, lack of homecare and postoperative support, and, for surgeons, access to operating rooms and resources, are perceived by physicians to routinely influence the ultimate choice of candidates for TJA. Medical brokering, defined as strategies used by physicians in a constrained health system to prioritize patients and to negotiate relationships with other physicians, was an important factor in determining candidacy for TJA. Because individual physicians and surgeons appear to use their own criteria for making these decisions, and because these criteria are modified from time to time in response to specific institutional and system conditions, brokering results in varied decisions about candidacy regardless of patient suitability. Conclusions. Lack of consensus on the necessary patient characteristics for TJA candidacy does not in and of itself account for the discrepancy between the number of patients who are suitable candidates for TJA and those who receive the procedure. Until the process by which health care system constraints affect and complicate the decision-making process around TJA candidacy is more fully explored, patients may not receive appropriate and timely access to this procedure.
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Affiliation(s)
- Pamela L. Hudak
- Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital and Department of Medicine, University of Toronto, Toronto, ON, .on.ca
| | - Pamela Grassau
- Ontario Breast Cancer Community Research Initiative, Psychosocial Behavioural Research Unit, Toronto, ON
| | - Richard H. Glazier
- Family & Community Medicine and Public Health Sciences, University of Toronto, Toronto, ON
| | - Gillian Hawker
- Medicine and Health Policy, Management and Evaluation, and Clinical Epidemiology and Health Care Research Program, University of Toronto, Toronto, ON
| | - Hans Kreder
- Orthopaedic Surgery & Health Policy, Management & Evaluation, University of Toronto, Toronto, ON
| | - Peter Coyte
- Department of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON
| | - Nizar Mahomed
- Department of Surgery, University of Toronto, Toronto, ON
| | - James G. Wright
- Surgery, Public Health Sciences, and Health Policy, Management and Evaluations, University of Toronto, Toronto, ON
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Sampietro-Colom L, Espallargues M, Rodríguez E, Comas M, Alonso J, Castells X, Pinto J. Wide Social Participation in Prioritizing Patients on Waiting Lists for Joint Replacement: A Conjoint Analysis. Med Decis Making 2008; 28:554-66. [DOI: 10.1177/0272989x08315235] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective. The aim was to develop a priority scoring system for patients on waiting lists for joint replacement based on a wide social participation, and to analyze the differences among participants. Methods. Conjoint analysis. Focus groups in combination with a nominal technique were employed to identify the priority criteria (N= 36). A rank-ordered logit model was then applied for scoring estimations. Participants (N= 860) represented: consultants, allied-health professionals, patients and their relatives, and the general population of Catalonia. Results. Clinical and social criteria were selected, and their relative importance (over 100 points) was: pain (33), difficulty in doing activities of daily living (21), disease severity (18), limitations on ability to work (10), having someone to look after the patient (9), being a caregiver (6), and recovery probability (4). Estimated criteria coefficients had the expected positive sign and all were statistically significant (P < 0.001). There were differences between groups; pain was rated higher by patients/relatives, and difficulty in doing activities was rated lower by patients/relatives and the general public. Most interaction terms for these criteria and groups were significant (P < 0.001). Consultants and allied-health professionals had the most similar prioritization pattern (r= 0.97). Conclusion. Both clinical and social criteria are considered for prioritization of joint replacement surgery from a wide social perspective. The preference among professional and social groups varies and this might impact the result of patient prioritization. A wide social participation for obtaining adequate prioritizing systems for patients on waiting lists is desirable.
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Affiliation(s)
- L. Sampietro-Colom
- Office for the Assessment of Innovation and New Technologies, Fundació Clínic, Barcelona, Spain, , Catalan Agency for Health Technology Assessment and Research (CAHTA), Barcelona, Spain
| | - M. Espallargues
- Catalan Agency for Health Technology Assessment and Research (CAHTA), Barcelona, Spain
| | - E. Rodríguez
- Department of Applied Economics, Universidad de Vigo, Vigo, Spain
| | - M. Comas
- Evaluation and Clinical Epidemiology Department, Hospital del Mar-IMAS, Barcelona, Spain, Health Services Research Unit, Institut Municipal d'Investigació Médica (IMIM-Hospital del Mar), Barcelona, Spain
| | - J. Alonso
- Health Services Research Unit, Institut Municipal d'Investigació Médica (IMIM-Hospital del Mar), Barcelona, Spain, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - X. Castells
- Evaluation and Clinical Epidemiology Department, Hospital del Mar-IMAS, Barcelona, Spain, Health Services Research Unit, Institut Municipal d'Investigació Médica (IMIM-Hospital del Mar), Barcelona, Spain (MC, JA, XC)
| | - J.L. Pinto
- Centre for Research in Economy and Health (CRES), Universitat Pompeu Fabra, Barcelona, Spain
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Dew K, Cumming J, McLeod D, Morgan S, McKinlay E, Dowell A, Love T. Explicit rationing of elective services: implementing the New Zealand reforms. Health Policy 2005; 74:1-12. [PMID: 16098407 DOI: 10.1016/j.healthpol.2004.12.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2004] [Accepted: 12/13/2004] [Indexed: 10/25/2022]
Abstract
In an attempt to make rationing of elective surgery in the publicly funded health system more explicit, New Zealand has developed a booking system for surgery using clinical priority assessment criteria (CPAC). This paper is based on research undertaken to evaluate the use of CPAC. To explore whether the goals of explicit rationing were being met 69 interviews were undertaken with policy advisors, administrators and clinicians in six localities throughout New Zealand. The aims of reforming policy for access to elective surgery included improving equity, providing clarity for patients, and achieving a paradigm shift by relating likely benefit from surgery to the available resources. The research suggests that there have been changes in the way in which patients access elective surgery and that in many ways rationing has become more explicit. However, there is also some resistance to the use of CPAC, in part due to confusion over whether the tools are decision-aids or protocols, what role the tools play in achieving equity and differences between financial thresholds for access to surgery and clinical thresholds for benefit from surgery. For many surgical specialties implicit rationing will continue to play a major part in determining access to surgery unless validated and reliable CPAC tools can be developed.
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Affiliation(s)
- Kevin Dew
- Department of Public Health, Wellington School of Medicine and Health Sciences, University of Otago, Wellington South, New Zealand.
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McLeod D, Morgan S, McKinlay E, Dew K, Cumming J, Dowell A, Love T. Clinicians' reported use of clinical priority assessment criteria and their attitudes to prioritization for elective surgery: a cross-sectional survey. ANZ J Surg 2004; 74:1003-9. [PMID: 15550092 DOI: 10.1111/j.1445-1433.2004.03151.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To explore the attitudes of clinicians working in New Zealand publicly funded hospitals towards prioritizing patients for elective surgery, and their reported use of clinical priority assessment criteria (CPAC). DESIGN A cross-sectional study using a postal questionnaire. The questionnaire drew on themes identified from an earlier qualitative study. Questions were closed and information was sought about perceptions of the need to prioritize patients, effective ways of doing so and the use of CPAC. SETTING New Zealand. PARTICIPANTS A national sample of cardiologists, cardiac, general and orthopaedic surgeons, and registrars. RESULTS Three hundred and thirty-two clinicians responded to the survey (74.1%). Respondents generally agreed that a nationally consistent method of prioritizing patients for surgery was required but felt their clinical judgement was the most effective way of prioritizing patients. Current CPAC were considered to be administrative tools and there was marked variation in their reported use. Consistent use of CPAC using the constructs provided was more likely to be reported by cardiac specialists than general or orthopaedic surgeons. Other features of the hospital system in which surgeons worked also had a major impact on access to elective surgery. CONCLUSIONS Clinicians recognized the need for a nationally consistent method of prioritizing patients. Although most did not consider current CPAC were effective in achieving this, many felt there was some potential in further development of tools. However, further development is problematic in the absence of objective measures of need and ability to benefit.
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Affiliation(s)
- Deborah McLeod
- Department of General Practice, Wellington School of Medicine and Health Sciences, Wellington, New Zealand.
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