Improving the quality of care with a single-entry model of referral for total joint replacement: a preimplementation/postimplementation evaluation

Abstract

ObjectivesWe assessed: (1) waiting time variation among surgeons; (2) proportion of patients receiving surgery within benchmark and (3) influence of the Winnipeg Central Intake Service (WCIS) across five dimensions of quality: accessibility, acceptability, appropriateness, effectiveness, safety.DesignPreimplementation/postimplementation cross-sectional design comparing historical (n=2282) and prospective (n=2397) cohorts.SettingRegional, provincial health authority.ParticipantsPatients awaiting total joint replacement of the hip or knee.InterventionsThe WCIS is a single-entry model (SEM) to improve access to total hip replacement (THR) or total knee replacement (TKR) surgery, implemented to minimise variation in total waiting time (TW) across orthopaedic surgeons and increase the proportion of surgeries within 26 weeks (benchmark). Impact of SEMs on quality of care is poorly understood.Primary and secondary outcome measuresPrimary outcomes related to ‘accessibility’: waiting time variation across surgeons, waiting times (Waiting Time 2 (WT2)=decision to treat until surgery and TW=total waiting time) and surgeries within benchmark. Analysis included descriptive statistics, group comparisons and clustered regression.ResultsVariability in TW among surgeons was reduced by 3.7 (hip) and 4.3 (knee) weeks. Mean waiting was reduced for TKR (WT2/TW); TKR within benchmark increased by 5.9%. Accessibility and safety were the only quality dimensions that changed (post-WCIS THR and TKR). Shorter WT2 was associated with post-WCIS (knee), worse Oxford score (hip and knee) and having medical comorbidities (hip). Meeting benchmark was associated with post-WCIS (knee), lower Body Mass Index (BMI) (hip) and worse Oxford score (hip and knee).ConclusionsThe WCIS reduced variability across surgeon waiting times, with modest reductions in overall waits for surgery. There was improvement in some, but not all, dimensions of quality.

The Effectiveness of Different Patient Referral Methods on Waiting Times for Adults Needing Elective Surgery - Systematic Review

“…Damani et al (35) reported a quasi-experimental study comparing a historical cohort (2397 patients recruited from 1 June 2011 to 1 June 2012) and a prospective cohort (2282 patients from 1 September 2013 to 1 September 2014) to assess the effects of a single-entry model (SEM) of referral to the next-available surgeon for total joint replacement surgeries in Canada. The results showed that the variability of waiting times among surgeons was reduced by 3.7 and 4.3 weeks for hip and knee replacements, respectively and there was a 5.6% increase in patients operated within the benchmark period.…”

“…Where there are multiple queues for surgical lists at the same surgery clinic, targeted patient referrals have had variable impacts on waiting times across different specialists. The application of single entry models (SEM) while pooling referrals enabled patients to see the next-available surgeon for their procedure and improved timeliness and e cient patient ow (35). The systematic review for SEM also showed a consistently positive impact on access-related variables for referral of patients to surgical clinics (51).…”

“…Of the ve studies, lower risk of bias in overall was found for the randomised trial (37). The other four studies were assessed as having medium risk of bias overall (35,36,39,40). The details of the ROBINS-I evaluation are shown in Figure 2 and Figure 3.…”

“…AMSTAR 2: One of three includes reviews was rated as high quality overall (43) and the other two were rated as moderate (35,41). All review protocols had been registered and the reviews presented adequate searches for literature in relevant databases.…”

Confronting the COVID-19 surgery crisis: time for transformational change

“…10,11 Bad care must be addressed by clinical leaders rather than the marketplace; group models of care actually make it easier to identify variations in practice and to support colleagues to improve the appropriateness and reliability of care and enhance surgeons' work environment. 12 Ultimately, surgeons want to perform operations for their patients. Many feel their careers and livelihoods are threatened by the COVID-19 restrictions on hospital activity.…”