Patient prioritisation methods to shorten waiting times for elective surgery: A systematic review of how to improve access to surgery

Abstract

Background Concern about long waiting times for elective surgeries is not a recent phenomenon, but it has been heightened by the impact of the COVID-19 pandemic and its associated measures. One way to alleviate the problem might be to use prioritisation methods for patients on the waiting list and a wide range of research is available on such methods. However, significant variations and inconsistencies have been reported in prioritisation protocols from various specialties, institutions, and health systems. To bridge the evidence gap in existing literature, this comprehensive systematic review will synthesise global evidence on policy strategies with a unique insight to patient prioritisation methods to reduce waiting times for elective surgeries. This will provide evidence that might help with the tremendous burden of surgical disease that is now apparent in many countries because of operations that were delayed or cancelled due to the COVID-19 pandemic and inform policy for sustainable healthcare management systems. Methods We searched PubMed, EMBASE, SCOPUS, Web of Science, and the Cochrane Library, with our most recent searches in January 2020. Articles published after 2013 on major elective surgery lists of adult patients were eligible, but cancer and cancer-related surgeries were excluded. Both randomised and non-randomised studies were eligible and the quality of studies was assessed with ROBINS-I and CASP tools. We registered the review in PROSPERO (CRD42019158455) and reported it in accordance with the PRISMA statement. Results The electronic search in five bibliographic databases yielded 7543 records (PubMed, EMBASE, SCOPUS, Web of Science, and Cochrane) and 17 eligible articles were identified in the screening. There were four quasi-experimental studies, 11 observational studies and two systematic reviews. These demonstrated moderate to low risk of bias in their research methods. Three studies tested generic approaches using common prioritisation systems for all elective surgeries in common. The other studies assessed specific prioritisation approaches for re-ordering the waiting list for a particular surgical specialty. Conclusions Explicit prioritisation tools with a standardised scoring system based on clear evidence-based criteria are likely to reduce waiting times and improve equitable access to health care. Multiple attributes need to be considered in defining a fair prioritisation system to overcome limitations with local variations and discriminations. Collating evidence from a diverse body of research provides a single framework to improve the quality and efficiency of elective surgical care provision in a variety of health settings. Universal prioritisation tools with vertical and horizontal equity would help with re-ordering patients on waiting lists for elective surgery and reduce waiting times.

The Oxford Knee Score is a reliable predictor of patients in a health state worse than death and awaiting total knee arthroplasty

“…Prioritizing patients on waiting lists has been recognized by several authors either by assigning surgical priority according to indications or using tools to help quantify prioritization [ 8 , 11 – 13 ]. Such tools often encompass patient factors, time spent on waiting list, and surgical factors.…”

“…All patients listed for knee arthroplasty are not equal and priority four will not be applicable to all patients [ 10 ]. Objective prioritization of patients is difficult, and authors have suggested prioritizing according to scores, applied ethics, and knee-specific function [ 8 , 11 – 13 ]. Prior studies have identified which patients may benefit from a total knee arthroplasty (TKA).…”

Prioritization versus rationing of healthcare – elective surgery is not optional surgery

“…9 Patients are commonly prioritized according to the time they have spent on a waiting list and/or surgical factors. [10][11][12][13] However, patients most in need of expeditious surgery may not receive it if this criterion is applied. Currently, surgical procedures are categorized as outlined above.…”

A novel multi-criteria decision-making approach for prioritization of elective surgeries through formulation of “weighted MeNTS scoring system”

“…In the literature [ 8 , 12 , 34 ], average waiting time has been considered important measure to evaluate the performance of the waiting list. It was found that there was appreciable reduction of 30.4% (from 4.246 days to 2.956 days) in the average wait time ( ) when the waiting list is prioritized.…”