Triage for coronary artery bypass graft surgery in Canada: do patients agree on who should come first?

BACKGROUND: The extent to which clinical and non-clinical factors impact on the waiting-list prioritization preferences of patients in the queue is unknown. Using a series of hypothetical scenarios, the objective of this study was to examine the extent to which clinical and non-clinical factors impacted on how patients would prioritize others relative to themselves in the coronary artery bypass surgical queue. METHODS: Ninety-one consecutive eligible patients awaiting coronary artery bypass grafting surgery at Sunnybrook Health Sciences Centre (median waiting-time duration prior to survey of 8 weeks) were given a self-administered survey consisting of nine scenarios in which clinical and non-clinical characteristic profiles of hypothetical patients (also awaiting coronary artery bypass surgery) were varied. For each scenario, patients were asked where in the queue such hypothetical patients should be placed relative to themselves. RESULTS: The eligible response rate was 65% (59/91). Most respondents put themselves marginally ahead of a hypothetical patient with identical clinical and non-clinical characteristics as themselves. There was a strong tendency for respondents to place patients of higher clinical acuity ahead of themselves in the queue (P < 0.0001). Social independence among young individuals was a positively valued attribute (P < 0.0001), but neither age per se nor financial status, directly impacted on patients waiting-list priority preferences. CONCLUSION: While patient perceptions generally reaffirmed a bypass surgical triage process based on principals of equity and clinical acuity, the valuation of social independence may justify further debate with regard to the inclusion of non-clinical factors in waiting-list prioritization management systems in Canada, as elsewhere.

Risk stratification, management and outcomes of patients with non-ST elevation acute coronary syndrome: a Canadian teaching hospital perspective.

BACKGROUND: Current guidelines for non-ST elevation acute coronary syndromes (NSTACS) recommend tailoring the intensity of therapeutic management according to the baseline risk of the patient. Although the clinical characteristics, risk stratification and therapeutic management of contemporary patients with NSTACS have been reported for other geographical regions, this information has not been documented from a Canadian perspective. OBJECTIVES: To describe the baseline clinical characteristics, therapeutic management and clinical outcomes of contemporary patients with NSTACS at a Canadian, tertiary care, teaching hospital, and to retrospectively risk stratify the patients with NSTACS according to the American College of Cardiology (ACC)/American Heart Association (AHA) and Thrombolysis in Myocardial Infarction (TIMI) risk guidelines to characterize management and outcomes according to the various risk classifications. METHODS: Baseline demographics, procedural variables and clinical outcome data were retrospectively collected in 380 patients with a diagnosis of NSTACS from July 1999 to July 2000. Patients were retrospectively categorized into high, intermediate and low risk categories using two classification schemes. RESULTS: According to the ACC/AHA guidelines, 10.3% and 89.7% of patients were intermediate and high risk, respectively. Applying the TIMI risk score, 20.0%, 52.4% and 27.6% of patients were low, intermediate and high risk, respectively. The use of antithrombotic, acetylsalicylic acid and beta-blocker therapy was very high both in hospital and at discharge. Glycoprotein IIb/IIIa inhibitors, angiotensin-converting enzyme inhibitors and lipid lowering agents were all underutilized. The use of pharmacological therapies and cardiovascular interventions did not appear to correlate with the level of risk of the patient, at least within these classification schemes. Adverse clinical events in hospital and length of hospital stay increased as the risk level of the patients increased. CONCLUSIONS: According to the ACC/AHA guidelines, patients with a discharge diagnosis of NSTACS in a nontrial setting are a high risk population, requiring prompt recognition and aggressive management. This study serves as an integral part of clinical practice to continually evaluate the quality of medical care.