Wait time management strategies for total joint replacement surgery: sustainability and unintended consequences.

BACKGROUND: In Canada, long waiting times for core specialized services have consistently been identified as a key barrier to access. Governments and organizations have responded with strategies for better access management, notably for total joint replacement (TJR) of the hip and knee. While wait time management strategies (WTMS) are promising, the factors which influence their sustainable implementation at the organizational level are understudied. Consequently, this study examined organizational and systemic factors that made it possible to sustain waiting times for TJR within federally established limits and for at least 18 months or more. METHODS: The research design is a multiple case study of WTMS implementation. Five cases were selected across five Canadian provinces. Three success levels were pre-defined: 1) the WTMS maintained compliance with requirements for more than 18 months; 2) the WTMS met requirements for 18 months but could not sustain the level thereafter; 3) the WTMS never met requirements. For each case, we collected documents and interviewed key informants. We analyzed systemic and organizational factors, with particular attention to governance and leadership, culture, resources, methods, and tools. RESULTS: We found that successful organizations had specific characteristics: 1) management of the whole care continuum, 2) strong clinical leadership; 3) dedicated committees to coordinate and sustain strategy; 4) a culture based on trust and innovation. All strategies led to relatively similar unintended consequences. The main negative consequence was an initial increase in waiting times for TJR and the main positive consequence was operational enhancement of other areas of specialization based on the TJR model. CONCLUSIONS: This study highlights important differences in factors which help to achieve and sustain waiting times. To be sustainable, a WTMS needs to generate greater synergies between contextual-level strategy (provincial or regional) and organizational objectives and constraints. Managers at the organizational level should be vigilant with regard to unintended consequences that a WTMS in one area can have for other areas of care. A more systemic approach to sustainability can help avoid or mitigate undesirable unintended consequences.

Perspectives of orthopaedic surgeons on patients' appropriateness for total joint arthroplasty: a qualitative study.

RATIONALE, AIMS AND OBJECTIVES: As total joint arthroplasty (TJA) rates rise, there is need to ensure appropriate use. Our objective was to elucidate surgeons' perspectives on appropriateness for TJA. METHODS: Semi-structured telephone interviews were conducted in a sample of orthopaedic surgeons that perform TJA in three Canadian Provinces. Surgeons were asked to discuss their criteria for TJA appropriateness for osteoarthritis; potential value of a decision-support tool to select appropriate candidates; and the role of other stakeholders in assessing appropriateness. RESULTS: Of 17 surgeons approached for participation, 14 completed interviews (12 males; 7 aged <50 years; 5 academic; 8 in urban practices). Surgeons agreed that pain and pain impact on patients' quality of life and function were the key criteria to assess appropriateness for TJA, but that these concepts were difficult to assess and not always congruent with structural changes on joint radiography. Some used a wider range of criteria, including their assessments of patient expectations, ability to cope and readiness for surgery. While patient age was not identified as a criterion itself, surgeons did acknowledge that appropriateness criteria may differ for younger versus older patients. Most agreed that a decision-support tool would help ensure that all elements of appropriateness are assessed in a standardized manner, albeit the ultimate decision to offer surgery must be left to the discretion of surgeons, within the context of the doctor-patient relationship. CONCLUSIONS: Surgeons recognized the need for a tool to support decision making for TJA, particularly in the context of increasing surgical demand in younger patients with less severe arthritis. The work to develop and test such a decision-support tool is underway.

Perspectives of Canadian Stakeholders on Criteria for Appropriateness for Total Joint Arthroplasty in Patients With Hip and Knee Osteoarthritis.

OBJECTIVE: As rates of total joint arthroplasty (TJA) for osteoarthritis (OA) rise, there is a need to ensure appropriate use. We undertook this study to develop criteria for appropriate use of TJA. METHODS: In prior work, we used qualitative methods to separately assess OA patients' and arthroplasty surgeons' perceptions regarding appropriateness of patient candidates for TJA. The current study reviewed the appropriateness themes that emerged from each group, and a series of statements were developed to reflect each unique theme or criterion. A group of arthroplasty surgeons then indicated their level of agreement with each statement using electronic voting. Where ≤70% agreed or disagreed, the criterion was discussed and revised, and revoting occurred. In standardized telephone interviews, OA patient focus group participants indicated their level of agreement with each revised criterion. RESULTS: Qualitative research in 58 OA patients and 14 arthroplasty surgeons identified 11 appropriateness criteria. Member-checking in 15 surgeons (including 5 who had participated in the qualitative study) resulted in agreement on 6 revised criteria. These included evidence of arthritis on joint examination, patient-reported symptoms negatively impacting quality of life, an adequate trial of appropriate nonsurgical treatment, realistic patient expectations of surgery, mental and physical readiness of patient for surgery, and patient-surgeon agreement that potential benefits exceed risks. Thirty-six of the original 58 OA patient focus group participants (62.1%) participated in the member-check interviews and endorsed all 6 criteria. CONCLUSION: Patients and surgeons jointly endorsed 6 criteria for assessment of TJA appropriateness in OA patients. Prospective validation of these criteria (assessed preoperatively) as predictive of postoperative patient-reported outcomes is under way and will inform development of a surgeon-patient decision-support tool for assessment of TJA appropriateness.

Sustainability: orthopaedic surgery wait time management strategies.

PURPOSE: The purpose of this paper is to examine Canadian organizational and systemic factors that made it possible to keep wait times within federally established limits for at least 18 months. DESIGN/METHODOLOGY/APPROACH: The research design is a multiple cases study. The paper selected three cases: Case 1 - staff were able to maintain compliance with requirements for more than 18 months; Case 2 - staff were able to meet requirements for 18 months, but unable to sustain this level; Case 3 - staff were never able to meet the requirements. For each case the authors interviewed persons involved in the strategies and collected documents. The paper analysed systemic and organizational-level factors; including governance and leadership, culture, resources, methods and tools. FINDINGS: Findings indicate that the hospital that was able to maintain compliance with the wait time requirements had specific characteristics: an exclusive mandate to do only hip and knee replacement surgery; motivated staff who were not distracted by other concerns; and a strong team spirit. ORIGINALITY/VALUE: The authors' research highlights an important gradient between three cases regarding the factors that sustain waiting times. The paper show that the hospital factory model seems attractive in a super-specialized surgery context. However, patients are selected for simple surgeries, without complications, and so this cannot be considered a unique model.

Criteria for Referring Patients With Outpatient Gastroenterological Disease for Specialist Consultation: A Review of the Literature.

BACKGROUND: Demands on gastroenterology are growing, as a result of the high prevalence of digestive diseases, the impact of colon cancer screening programs and an aging population. Prioritizing referrals to gastroenterology would assist in managing wait times. Our objectives were (1) to assess whether there were consistent criteria to guide referrals from family physicians for gastroenterological outpatient consultation and (2) to determine if there were different levels of urgency or priority in referral criteria. METHODS: We conducted a scoping review, searching Medline, Embase and Cochrane databases from 1997 to 2009, using the terms referral, triage, consultation and at least one from a list of gastroenterology-specific search terms. Of 2978 initial results, 51 papers were retrieved, and 20 were retained after review by two reviewers. Additional publications were identified through hand searches of retained papers, website searches and nomination by a panel of specialists. RESULTS: Thirty-four papers, reports or websites were retained. No referral criteria covered the spectrum of disorders that might be referred by family physicians to gastroenterologists. Criteria for referral were most commonly listed for suspected colorectal cancer, followed by suspected upper GI cancer, hepatitis, and functional disorders. CONCLUSIONS: A clinical panel comprised of gastroenterologists and primary care providers, informed by this literature review, are completing the work of formulating a Gastroenterology Priority Referral Score, and plan to test the reliability and validity of the tool for determining the relative urgency for referral from primary care to gastroenterology.

Predictors of serious complications associated with lower gastrointestinal endoscopy in a major city-wide health region.

BACKGROUND: There are limited data regarding complications associated with colonoscopy and flexible sigmoidoscopy in usual clinical practice in Canada. OBJECTIVE: To determine the risk factors for lower gastrointestinal (GI) endoscopy-associated complications in usual clinical practice. METHODS: All outpatient lower GI endoscopies performed in Winnipeg (Manitoba) between April 1, 2004 and March 31, 2006, were identified from the provincial physicians' claims database. All subsequent hospital admissions within 30 days that documented potential complications associated with lower GI endoscopies were identified from the electronic hospital discharges database and reviewed. Multivariate generalized estimating equation regression analysis was performed to determine independent factors (patient, endoscopist and procedure) associated with the risk of developing complications. RESULTS: There were 29,990 outpatient lower GI endoscopies performed in Winnipeg during the years studied. Seventy-seven (0.26%) procedures were associated with complications requiring hospitalization within 30 days of the index procedure. Stricture dilation (rate ratio [RR] 23.14; 95% CI 6.70 to 76.51), polypectomy (RR 5.93; 95% CI 3.66 to 9.62), increasing patient age (for each year increase in age, RR 1.03; 95% CI 1.01 to 1.05) and performance of endoscopy by low-volume endoscopists (fewer than 200 procedures per year, RR 2.28; 95% CI 1.18 to 4.42) and family physicians (RR 2.23; 95% CI 1.39 to 3.58) were independently associated with complications. CONCLUSIONS: The results of the present study suggest that increasing patient age, complex procedures and performance of the index procedure by low-volume endoscopists are independent risk factors for lower GI endoscopy-associated complications in usual clinical practice. This suggests that it may be time to consider implementing minimum volume requirements for endoscopists performing non-screening lower GI endoscopies.

Comparison and validity of procedures coded With ICD-9-CM and ICD-10-CA/CCI.

BACKGROUND: The use of health administrative data in health services research is facilitated by standardized classification systems, such as the International Classification of Diseases (ICD). Canada, among other countries, recently introduced the tenth version of ICD and its accompanying Canadian Classification of Interventions (CCI). It is imperative to assess errors that could occur in administrative data due to the introduction of the new coding system. OBJECTIVE: To evaluate the validity of procedure coding in hospital discharge data, comparing CCI with ICD-9-CM. RESEARCH DESIGN: Trained reviewers examined 4008 randomly selected charts from 4 teaching hospitals in Alberta, Canada, for the presence of 30 procedures. The charts, already coded using CCI, were recoded using ICD-9-CM. Comprehensive lists of procedure codes in both systems were identified using literature, health records technicians, surgeons and online resources. MEASURES: Three databases were created for the same hospital discharge record, including CCI, ICD-9-CM, and chart review data. Sensitivity, specificity, positive predictive value, negative predictive value and kappa scores were calculated. RESULTS: Compared with the chart review data, ICD-9-CM data under-reported 17 procedures, over-reported 12, and equivalently reported 1. CCI data under-reported 19 procedures, over-reported 9, and equivalently reported 2. Kappa value was within 0.1 difference between ICD-9-CM and CCI for 14 procedures. CONCLUSIONS: Both ICD-9-CM and CCI coded the more major or invasive procedures reasonably well, but were not valid for less invasive or minor procedures. CCI can be used by health services and population health researchers with as much confidence as ICD-9-CM.

Priority-setting tools for rheumatology disease referrals: a review of the literature.

As part of a larger body of work to develop a rheumatology priority referral score, a literature review was conducted. The objective of the literature review was to identify preexisting priority-setting, triage, and referral tools/scales developed to guide referrals from primary care to specialist care/consultation usually provided by a rheumatologist. Using a combination of database, citation, Internet, and hand-searching, 20 papers were identified that related to referral prioritization in three areas: rheumatoid arthritis (RA; 5), musculoskeletal (MSK) diseases other than RA (3), and MSK diseases in general (12). No single set of priority-setting criteria was identified for rheumatologic disorders across the spectrum of patients who may be referred from primary care providers (PCPs) to rheumatologists. There appears to be more congruence on conditions at either end of the urgency spectrum with conditions such as suspected cranial arteritis or systemic vasculitis deemed to be emergency referrals and fibromyalgia and other soft-tissue syndromes deemed to be more routine referrals. Between these two extremes, there is a divergence of opinion about urgency and few papers on the issue. The exception to this is referral for early RA for which several criteria have been established. Despite the inherent complexities in developing a tool to prioritize patients referred by PCPs to rheumatologists, there are compelling reasons to proceed. With the aging of the population, the number of patients being referred to rheumatologists is expected to increase. With pharmaceutical advances, there are demonstrable benefits in early referral for some conditions. These trends have led to increased pressure on scarce rheumatological human resources. A tool to prioritize referrals is a critical component of improving access and the referral process.

Do administrative databases accurately measure waiting times for medical care? Evidence from general surgery.

We abstracted the records of patients from general surgeons' offices in Winnipeg to compare waiting times from charts (i.e., the gold standard) with waiting times using administrative data. The administrative data method relies on physicians' billing data to identify a visit to the surgeon preoperatively to mark the start of the waiting time. There was no difference between waiting times using patient records versus administrative data. The study supported the use of administrative data to monitor waiting times.

A systematic literature review of the evidence on benchmarks for cataract surgery waiting time.

BACKGROUND: This review offered critical input to the work of Canadian federal-provincial-territorial Deputy Ministers of Health on establishing evidence-based benchmarks for waiting times (WTs) for cataract surgery. The study purpose was to synthesize the evidence regarding the relations among patient characteristics, WT, and health outcomes for patients on waiting lists for cataract surgery. METHODS: A systematic literature review was conducted using the Cochrane methodology. RESULTS: Seventeen studies were considered. The studies varied in their quality, study design, sample characteristics, and outcome measures. Because of the heterogeneity in studies, a qualitative analysis was used. Key findings were: individuals with cataracts are at an increased risk of falls, hip fractures, and motor vehicle crashes, the absence of pre-existing eye disease, and better baseline visual acuity and visual function are associated with better outcomes, and average WTs of 6-12 months are associated with a decline in visual acuity in patients while waiting. INTERPRETATION: Although the evidence does not indicate a precise benchmark, it does support timely access to surgery for individuals undergoing cataract surgery. In December 2005, health ministers set a goal to provide cataract surgery within 16 weeks for patients at high risk.

Health care utilization for injury in cataract surgery patients.

BACKGROUND: Although visual impairment has been associated with falls, fractures, and other injuries, the relation between cataract surgery and injuries is unclear. This study assesses whether persons waiting for cataract surgery are at increased risk of requiring health care services for an injury compared with a control group, and, if so, whether the risk changes after cataract surgery. METHODS: This is a retrospective case-control study of first-eye cataract surgery recipients in Manitoba in fiscal 1999-2000. Health care administrative data and cataract waiting list registry data were the data sources. Cataract surgery recipients were matched 3:1 with controls on age, sex, and region. The outcome measure was a diagnosis of injury identified using International Classification of Diseases 9 (Clinical Modification) codes in the physician or hospital claims. Data were analyzed for 2 years before and after cataract surgery. A multivariate logistic regression adjusted for potential confounders, such as burden of illness, presence of diabetes, stroke or dementia, number of different medications, and use of psychoactive mediations. RESULTS: There were 3811 cases and 11,359 controls. Cases were found to be much more likely to have a history of stroke, diabetes, or dementia, and were more likely to have been prescribed multiple medications or a psychoactive drug. After adjustment for comorbidities and pharmaceutical use, cases had a significantly higher probability of an injury before surgery (0.2784 vs. 0.2538; chi2 = 5.01, p = 0.03). This decreased significantly after surgery to 0.2333 (chi2 = 18.05, p < 0.0001). After surgery, the adjusted probability of injury was lower among cases (0.2333) than controls (0.2385), though this was not significant. The adjusted odds ratio for having an injury was 1.032 (95% confidence interval 1.026, 1.039) per week of waiting. INTERPRETATION: Cataract patients have a significantly increased risk of injury compared with controls before surgery, but their risk decreases to that of controls following surgery. Given that cataract patients also bear a much heavier burden of illness, including conditions that are associated with a higher risk of falls and injuries, the imperative of performing cataract surgery without delay becomes even more pressing.

The Western Canada Waiting List Project: development of a priority referral score for hip and knee arthroplasty.

BACKGROUND: Recognizing the concerns about long waiting times to see some specialists in Canada, and the burden this places on both primary care and specialist clinicians, the Western Canada Waiting List (WCWL) undertook the Primary Care Project. The goal was to develop a valid, reliable, standardized prioritization tool for use by primary care providers in making referrals to specialists. WCWL is a 20-partner collaboration committed to addressing long waiting times to access scheduled health care services. METHODS: A previously developed prioritization tool for hip and knee replacement was adapted for use by family doctors, based on expert feedback from a clinical panel of primary care providers and from orthopaedic surgeons. Rater assessments of standardized paper cases were used to generate weights for criteria items in the Priority Referral Score (PRS). Intraclass correlations (ICCs) were calculated to assess reproducibility, and weights were estimated using a mixed-effects model. The weights and criteria items were modified following feedback of these results to the panel. The resulting PRS was reliability-tested with a different set of standardized case descriptions. RESULTS: One item was removed from the Hip and Knee Surgery tool and two items more pertinent to family medicine (mobility and medications) were added. The resulting eight-item PRS had a test-retest ICC of 0.84. The mean intrarater ICC was 0.79. CONCLUSIONS: An eight-item priority-setting tool has been developed to assist in queuing patients in order of urgency when they are referred to an orthopaedic surgeon for possible hip or knee arthroplasty. The tool had excellent inter- and intrarater reliability and was seen to have face validity by a panel of primary care providers who advised on the project.

Mortality, cause of death and life expectancy of Chinese Canadians in Alberta.

OBJECTIVE: To describe mortality, cause of death and life expectancy among Chinese (both immigrant and Canadian-born) and other Canadians in the Province of Alberta. METHODS: A Chinese surname list was applied to the Alberta Health Insurance Plan and Vital Statistics Birth registry databases to define the Chinese population, and to the Vital Statistics Death registry to determine deaths among Chinese in Alberta from 1995 to 2003. Age- and sex-specific mortality, cause of death and life expectancy were calculated. RESULTS: Of nearly 3 million Alberta residents, about 4% were Chinese in 2003. The age-adjusted mortality for Chinese was 4.2 per 1000 and for non-Chinese 6.2 per 1000 population. Infant mortality was lower for Chinese (4.9/1000 live births) than non-Chinese (6.2/1000 live births). Life expectancy at birth was 6.3 years longer for Chinese males compared to non-Chinese males (83.3 versus 77.0), and 5.4 years longer for Chinese females compared to non-Chinese females (87.9 versus 82.5). Cancer, heart disease and stroke were the leading causes of death for both Chinese and non-Chinese Albertans. CONCLUSIONS: The Chinese ethnic population of Alberta had lower mortality and longer life expectancy than remaining Albertans, suggesting that the Chinese population has better health status than other Albertans. Reasons for the health gap between Chinese and non-Chinese populations should be further explored.

Variation in health services utilization among ethnic populations.

BACKGROUND: Although racial and ethnic disparities in health services utilization and outcomes have been extensively studied in several countries, this issue has received little attention in Canada. We therefore analyzed data from the 2001 Canadian Community Health Survey to compare the use of health services by members of visible minority groups and nonmembers (white people) in Canada. METHODS: Logistic regression was used to compare physician contacts and hospital admissions during the 12 months before the survey and recent cancer screening tests. Explanatory variables recorded from the survey included visible minority status, sociodemographic factors and health measures. RESULTS: Respondents included 7057 members of visible minorities and 114,255 white people for analysis. After adjustments for sociodemographic and health characteristics, we found that minority members were more likely than white people to have had contact with a general practitioner (adjusted odds ratio [OR] 1.28, 95% confidence interval [CI] 1.14-1.42), but not specialist physicians (OR 1.01, 95% CI 0.93-1.10). Members of visible minorities were less likely to have been admitted to hospital (OR 0.83, 95% CI 0.70- 0.98), tested for prostate-specific antigen (OR 0.64, 95% CI 0.52-0.79), administered a mammogram (OR 0.68, 95% CI 0.59-0.80) or given a Pap test (OR 0.47, 95% CI 0.39-0.56). INTERPRETATION: Use of health services in Canada varies considerably by ethnicity according to type of service. Although there is no evidence that members of visible minorities use general physician and specialist services less often than white people, their utilization of hospital and cancer screening services is significantly less.

Non-clinical factors associated with variation in cataract surgery waiting times in Manitoba.

Cataract surgery is the highest-volume surgical procedure in Canada, with over 200,000 performed annually, mostly (85%) on persons aged 65 or older. Concerns have been raised about wait times to access this procedure. This study explores the relationship between waiting times for cataract surgery in Manitoba and a variety of characteristics, including age, sex, socio-economic status, region of residence, health status, surgeon, and surgeon's caseload. The study included 6114 individuals who had first-eye cataract surgery between November 1, 1998, and March 31, 2000, in Winnipeg, MB. Significant predictors of variation in wait times were age, sex, having a hospitalization while waiting, and surgeon. The model explained 32.5 per cent of the variance in wait times; specific surgeon independently explained 29.5 per cent of the variance. Median waiting times varied widely by surgeon, ranging from 61 to 399 days. Differences in surgeons' expected wait times should be available to patients and referring clinicians.