Turning ‘waiting lists’ for elective surgery into ‘preparation lists’

Abstract

Waiting lists for surgery are an integral part of the UK National Health Service (NHS); they are used as a construct to ration surgery and to reduce costs, whilst simultaneously attempting to distribute limited health resources in an equitable manner.1Lindsay C.M. Feigenbaum B. Rationing by waiting lists.Am Econ Rev. 1984; 74: 404-417PubMed Google Scholar They are a feature of health services that have central funding, financed mainly through general taxation, and are present in several other European countries including Italy, Greece, and Spain, where there is a need to manage the dynamics of capacity and demand. Waiting lists are rarer in countries that rely on private healthcare provision (including insurance) or rely on funding through social security (e.g. USA, Austria, Germany, and France).2Cerdá E. de Pablos L. Rodríguez M.V. Waiting lists for surgery.in: Hall R.W. Patient flow: reducing delay in healthcare delivery. Springer, New York, NY2013: 197-227Crossref Scopus (2) Google Scholar Nevertheless, independent of the healthcare system, there is an inevitable period of time between diagnosis of an illness that may be amenable to surgery and admission for elective surgery. It is now acknowledged that this time can be better spent in preparing patients for surgery in order to improve the patients' experience of healthcare (including quality outcomes and satisfaction), improve population/public health, and reduce the per capita costs of healthcare. This triad forms the central premise of the US Institute for Healthcare Improvement's widely supported and emulated ‘triple aim’ healthcare initiative,3Berwick D.M. Nolan T.W. Whittington J. The triple aim: care, health, and cost.Health Aff (Millwood). 2008; 27: 759-769Crossref PubMed Scopus (3006) Google Scholar to which the fourth (quadruple) aim of improving the experience of providing care and attaining joy in work may be added.4Feeley D. The triple aim or the quadruple aim? Four points to help set your strategy. Institute for Healthcare Improvement, Boston, MA2017http://www.ihi.org/communities/blogs/the-triple-aim-or-the-quadruple-aim-four-points-to-help-set-your-strategyDate accessed: July 30, 2020Google Scholar Better care gives an increased sense of accomplishment and meaning for healthcare workers, and may also improve overall delivery of healthcare.5NHS Wales NHS Wales planning framework 2019/22.http://www.wales.nhs.uk/sitesplus/documents/862/Item%205.1.1%20NHS%20Wales%20Planning%20Framework%202019-22.pdfDate accessed: July 30, 2020Google Scholar,6NHS England We are the NHS: people plan for 2020/2021 – action for us all.2020https://www.england.nhs.uk/ournhspeople/Date accessed: July 30, 2020Google Scholar Although waiting lists are sometimes viewed as a means to create a delay in the delivery of surgical care, if the time is utilised well, the patient can be optimised for surgery, resulting in a better outcome. Hence, we propose that ‘preparation lists’ may be a more appropriate name for the time spent between listing and admitting patients for the surgery. Global life expectancy is increasing, and with it, the associated comorbidity. For example, in the USA, the population aged more than 65 yr increased by 34% from 37.8 million in 2007 to 50.9 million in 2017 and is projected to reach 94.7 million in 2060.7Administration for Community Living and Administration on Aging2018 profile of older Americans. Administration on Aging (AoA), Administration for Community Living, US Department of Health and Human Services, 2018https://acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/2018OlderAmericansProfile.pdfDate accessed: July 30, 2020Google Scholar The population having surgery in England is ageing at a faster rate than the general population.8Fowler A.J. Abbott T.E.F. Prowle J. Pearse R.M. Age of patients undergoing surgery.Br J Surg. 2019; 106: 1012-1018Crossref PubMed Scopus (54) Google Scholar The 2018 US data exemplify the relationship between increasing age and comorbidities, with 38% of people aged 65 yr or more having one or no chronic conditions, 47% two to three chronic conditions, and 15% four or more chronic conditions,7Administration for Community Living and Administration on Aging2018 profile of older Americans. Administration on Aging (AoA), Administration for Community Living, US Department of Health and Human Services, 2018https://acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/2018OlderAmericansProfile.pdfDate accessed: July 30, 2020Google Scholar with the main chronic conditions being hypertension, arthritis, heart disease, diabetes mellitus, cancer, and stroke.7Administration for Community Living and Administration on Aging2018 profile of older Americans. Administration on Aging (AoA), Administration for Community Living, US Department of Health and Human Services, 2018https://acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/2018OlderAmericansProfile.pdfDate accessed: July 30, 2020Google Scholar Multimorbidity matters as it is associated with higher mortality, polypharmacy, higher rates of adverse drug events (including drug–disease interactions and drug–drug interactions), and increased utilisation of healthcare resources.9Farmer C. Fenu E. O'Flynn N. Guthrie B. Clinical assessment and management of multimorbidity: summary of NICE guidance.BMJ. 2016; 354: i4843Crossref PubMed Scopus (106) Google Scholar The increasing prevalence and adverse impact of frailty on surgical outcomes are also being appreciated better now.10Chan S.P. Ip K.Y. Irwin M.G. Peri-operative optimisation of elderly and frail patients: a narrative review.Anaesthesia. 2019; 74: 80-89Crossref PubMed Scopus (34) Google Scholar It is estimated that in excess of 4 million people die each year within 30 days of surgery globally, and that postoperative deaths now account for 7.7% of deaths worldwide, making surgery the third leading cause of death after ischaemic heart disease and stroke.11Nepogodiev D. Martin J. Biccard B. Makupe A. Bhangu A. National Institute for Health Research Global Health Research Unit on Global SurgeryGlobal burden of postoperative death.Lancet. 2019; 393: 401Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar In addition to causing immediate mortality, surgical complications are associated with increased healthcare costs,12Eappen S. Lane B.H. Rosenberg B. et al.Relationship between occurrence of surgical complications and hospital finances.JAMA. 2013; 309: 1599-1606Crossref PubMed Scopus (130) Google Scholar long-term morbidity, reduced quality of life, and increased risk of premature death for several years after the procedure.13Khuri S.F. Henderson W.G. DePalma R.G. et al.Determinants of long-term survival after major surgery and the adverse effect of postoperative complications.Ann Surg. 2005; 242 (discussion 41–3): 326-341Crossref PubMed Scopus (907) Google Scholar,14Moonesinghe S.R. Harris S. Mythen M.G. et al.Survival after postoperative morbidity: a longitudinal observational cohort study.Br J Anaesth. 2014; 113: 977-984Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar These complications may also prevent patients from returning to their usual or previous place of residence, as they require increased levels of care, which adds further to the overall costs. Hence, quality of recovery, which encompasses the concept of the patient returning to their previous level of function or better, is an important outcome.15Ladha K.S. Wijeysundera D.N. Role of patient-centred outcomes after hospital discharge: a state-of-the-art review.Anaesthesia. 2020; 75: e151-e157PubMed Google Scholar,16Levy N. Grocott M.P.W. Lobo D.N. Restoration of function: the holy grail of peri-operative care.Anaesthesia. 2020; 75: e14-e17PubMed Google Scholar Thus, the current challenges of surgery now include dealing with complications arising from an ageing population, increasing prevalence of frailty and multimorbidity, issues with polypharmacy, and adverse drug events, all within economies in which there is a need to curtail costs. In addition, there are now greater public expectations from healthcare providers, and often these expectations can exceed the ability of healthcare to improve health. The concept of the global ‘Choosing Wisely’ initiative is to improve the value of conversations between patients and their healthcare providers, to increase use of a shared decision-making tool, resulting in realistic expectations and minimisation of unnecessary and potentially harmful interventions.17Santhirapala R. Fleisher L.A. Grocott M.P.W. Choosing wisely: just because we can, does it mean we should?.Br J Anaesth. 2019; 122: 306-310Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar The time spent by patients waiting for an elective operation should be used to prepare them for surgery medically, physically, and psychologically by instituting measures that have been shown to improve postoperative outcomes. The process should commence as soon as the diagnosis is made and the decision to proceed with an operation is contemplated. The whole preparation process is multimodal and may involve several specialties, departments, and healthcare professional groups (Fig. 1). The process may take several weeks for some of the components, but many can be completed within 2–4 weeks. Even for patients requiring surgery for cancer, this would not result in a delay, provided the process is commenced once surgery is contemplated.18NIHR Cancer and Nutrition CollaborationRoyal College of AnaesthetistsMacmillan Cancer SupportPrehabilitation for people with cancer: Principles and guidance for prehabilitation within the management and support of people with cancer. Macmillan.org.uk, London2019https://www.macmillan.org.uk/assets/prehabilitation-guidance-for-people-with-cancer.pdfDate accessed: July 30, 2020Google Scholar Nevertheless, the process should not be allowed to delay surgical intervention unnecessarily for conditions that need prompt attention or where an inordinate delay could result in harm. Individualised risk assessment and shared decision-making lie at the heart of preparing patients for surgery. The shared decision-making process should begin at the initial surgical consultation with discussions between the surgeon, patient, carers, and family. If a patient is clearly not fit for the planned procedure or does not wish to proceed, it is not prudent to put them through the whole process of preparation, and the alternatives, including doing nothing, should be discussed at that point. However, shared decision-making may be easier after appropriate investigations and formal risk assessment, and often involves other healthcare professionals.18NIHR Cancer and Nutrition CollaborationRoyal College of AnaesthetistsMacmillan Cancer SupportPrehabilitation for people with cancer: Principles and guidance for prehabilitation within the management and support of people with cancer. Macmillan.org.uk, London2019https://www.macmillan.org.uk/assets/prehabilitation-guidance-for-people-with-cancer.pdfDate accessed: July 30, 2020Google Scholar Formal risk assessment coupled with shared decision-making may help reduce last-minute cancellations and improve the patient experience. In the USA, the focus of the Choosing Wisely campaign has primarily been to improve the professionalism around the patient–clinician interaction with the aim of reducing unnecessary interventions by publishing lists of diagnostic tests and interventions that have low or no health benefit value. These interventions can be driven by monetary gain for healthcare providers and patient demand, often resulting in higher stakes for patients when the procedure results in no improvement or deterioration in the quality of health of the patient.19Berlin N.L. Skolarus T.A. Kerr E.A. Dossett L.A. Too much surgery: overcoming barriers to deimplementation of low-value surgery.Ann Surg. 2020; 271: 1020-1022Crossref PubMed Scopus (7) Google Scholar In the UK, the emphasis has been on utilising shared decision-making to minimise the use of health interventions that have either no or limited health benefit for individual patients.17Santhirapala R. Fleisher L.A. Grocott M.P.W. Choosing wisely: just because we can, does it mean we should?.Br J Anaesth. 2019; 122: 306-310Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Choosing Wisely UK20Choosing Wisely UK https://www.choosingwisely.co.uk/about-choosing-wisely-uk/Date accessed: July 30, 2020Google Scholar suggest that the patient should ask their doctor or nurse the following four BRAN questions, which enable the patient and clinician to have a dialogue on the unique circumstances and values that are pertinent to the individual patient and enable discussions around patient-centred outcomes:•What are the Benefits?•What are the Risks?•What are the Alternatives?•What happens if I do Nothing? Furthermore, these questions compliment the use of risk calculators that quantify the probability of death and morbidity of that procedure in a population that is similar to the individual. Patients often find discussing these patient-centred outcomes more meaningful if the risk of not being able to return to the previous level of function or domestic situation is considered.15Ladha K.S. Wijeysundera D.N. Role of patient-centred outcomes after hospital discharge: a state-of-the-art review.Anaesthesia. 2020; 75: e151-e157PubMed Google Scholar,16Levy N. Grocott M.P.W. Lobo D.N. Restoration of function: the holy grail of peri-operative care.Anaesthesia. 2020; 75: e14-e17PubMed Google Scholar This information allows the alternative options, including doing nothing, to be discussed and is dependent on the patient's individual values, perspectives, and risk factors. Individualised risk assessment not only identifies the patient's fixed risk factors, but can also identify modifiable risk factors. The impact of these modifiable risk factors can be diminished during the preparation time through the processes of multimodal prehabilitation, and optimisation of lifestyle, concurrent disease or comorbidity, and drug therapy. ‘Surgery schools’ are an exciting concept that are being used by an increasing number of surgical departments to educate patients about the pathway, to ensure that they are well motivated, and are aware of their responsibilities in promoting their own recovery.18NIHR Cancer and Nutrition CollaborationRoyal College of AnaesthetistsMacmillan Cancer SupportPrehabilitation for people with cancer: Principles and guidance for prehabilitation within the management and support of people with cancer. Macmillan.org.uk, London2019https://www.macmillan.org.uk/assets/prehabilitation-guidance-for-people-with-cancer.pdfDate accessed: July 30, 2020Google Scholar,21Levett D.Z.H. Grimmett C. Psychological factors, prehabilitation and surgical outcomes: evidence and future directions.Anaesthesia. 2019; 74: 36-42Crossref PubMed Scopus (56) Google Scholar Multimodal prehabilitation is the process of reducing surgical complications through the triad of physical fitness training, optimising nutritional status, and improving psychological resilience. A systematic review of nine studies showed that nutritional prehabilitation alone or combined with an exercise program in patients undergoing colorectal surgery significantly shortened length of hospital stay by 2 days, and also accelerated the return to preoperative functional capacity.22Gillis C. Buhler K. Bresee L. et al.Effects of nutritional prehabilitation, with and without exercise, on outcomes of patients who undergo colorectal surgery: a systematic review and meta-analysis.Gastroenterology. 2018; 155 (e4): 391-410Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar Further lifestyle interventions including weight reduction in patients with obesity and smoking cessation can also help reduce surgical complications and improve outcome. In addition, these interventions (increased physical activity levels, improved dietary intake, reduced alcohol intake, and smoking cessation) are the main modifiable risk factors for non-communicable diseases in the Western world. Long-term compliance with these interventions improves the general health of the patient and, thus, the preparation time before surgery offers a powerful ‘teachable moment’ for the patient. The risk of developing surgical complications and the tangible ability to improve the immediate outcome provide incentive to implement these lifestyle changes permanently.18NIHR Cancer and Nutrition CollaborationRoyal College of AnaesthetistsMacmillan Cancer SupportPrehabilitation for people with cancer: Principles and guidance for prehabilitation within the management and support of people with cancer. Macmillan.org.uk, London2019https://www.macmillan.org.uk/assets/prehabilitation-guidance-for-people-with-cancer.pdfDate accessed: July 30, 2020Google Scholar The preparation period also allows comorbidities to be optimised.16Levy N. Grocott M.P.W. Lobo D.N. Restoration of function: the holy grail of peri-operative care.Anaesthesia. 2020; 75: e14-e17PubMed Google Scholar It is now accepted that, amongst other conditions, anaemia, poorly controlled diabetes mellitus, opioid use, and fast atrial fibrillation should all be optimised in order to improve surgical outcome. In addition to reducing the burden of comorbidities, there is a need to manipulate or modify the patient's drugs. Certain drugs such as insulin and anticoagulants will need to be dose-adjusted, stopped, or modified to a different formulation to allow anaesthesia and surgery to proceed safely. Preoperative use of opioids and other dependence-forming medicines are significant risk factors for chronic postsurgical pain and persistent postoperative opioid use, and there is now the recognised need to wean these drugs preoperatively.23Edwards D.A. Hedrick T.L. Jayaram J. et al.American Society for Enhanced Recovery and Perioperative Quality Initiative joint consensus statement on perioperative management of patients on preoperative opioid therapy.Anesth Analg. 2019; 129: 553-566Crossref PubMed Scopus (27) Google Scholar There is also the increasing realisation that psychological factors, including dispositional optimism and propensity to engage in adaptive health behaviours, improve certain short-term and long-term surgical outcomes.21Levett D.Z.H. Grimmett C. Psychological factors, prehabilitation and surgical outcomes: evidence and future directions.Anaesthesia. 2019; 74: 36-42Crossref PubMed Scopus (56) Google Scholar This is a further rationale behind the development of personalised health coaching apps and ‘surgery schools’, as they have also been shown to reduce patient anxiety, postoperative pain, and length of stay with improved patient satisfaction.21Levett D.Z.H. Grimmett C. Psychological factors, prehabilitation and surgical outcomes: evidence and future directions.Anaesthesia. 2019; 74: 36-42Crossref PubMed Scopus (56) Google Scholar Patient involvement and engagement are essential components of enhanced recovery after surgery (ERAS) patient partnership programmes.24Gustafsson U.O. Scott M.J. Hubner M. et al.Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations: 2018.World J Surg. 2019; 43: 659-695Crossref PubMed Scopus (430) Google Scholar Patients gain greater understanding of the importance of taking responsibility for increasing physical activity and improving dietary and other lifestyle choices both before and after surgery, and become active partners in the process to improve their health, rather than just passive recipients of healthcare.18NIHR Cancer and Nutrition CollaborationRoyal College of AnaesthetistsMacmillan Cancer SupportPrehabilitation for people with cancer: Principles and guidance for prehabilitation within the management and support of people with cancer. Macmillan.org.uk, London2019https://www.macmillan.org.uk/assets/prehabilitation-guidance-for-people-with-cancer.pdfDate accessed: July 30, 2020Google Scholar The conversion of waiting lists to preparation lists involves a societal change in expectations, but also process changes in healthcare systems, and as with any other major change faces many barriers, some of which have been identified in previous studies.25AlBalawi Z. Gramlich L. Nelson G. Senior P. Youngson E. McAlister F.A. The impact of the implementation of the Enhanced Recovery After Surgery (ERAS®) Program in an entire health system: a natural experiment in Alberta, Canada.World J Surg. 2018; 42: 2691-2700Crossref PubMed Scopus (10) Google Scholar, 26Byrnes A. Young A. Mudge A. Banks M. Bauer J. EXploring practice gaps to improve PERIoperativE Nutrition CarE (EXPERIENCE Study): a qualitative analysis of barriers to implementation of evidence-based practice guidelines.Eur J Clin Nutr. 2019; 73: 94-101Crossref PubMed Scopus (12) Google Scholar, 27Gramlich L.M. Sheppard C.E. Wasylak T. et al.Implementation of Enhanced Recovery After Surgery: a strategy to transform surgical care across a health system.Implement Sci. 2017; 12: 67Crossref PubMed Scopus (57) Google Scholar, 28Pearsall E.A. Meghji Z. Pitzul K.B. et al.A qualitative study to understand the barriers and enablers in implementing an Enhanced Recovery After Surgery program.Ann Surg. 2015; 261: 92-96Crossref PubMed Scopus (122) Google Scholar Some of these are more complex than others and include financial and behavioural constraints that lead to an unwillingness or reluctance to change. Nevertheless, the prospect of surgery remains a powerful and highly effective stimulus to effect change, and with appropriate patient support, these barriers can be overcome and the quadruple aim4Feeley D. The triple aim or the quadruple aim? Four points to help set your strategy. Institute for Healthcare Improvement, Boston, MA2017http://www.ihi.org/communities/blogs/the-triple-aim-or-the-quadruple-aim-four-points-to-help-set-your-strategyDate accessed: July 30, 2020Google Scholar realised (Fig. 2). With the changing patient characteristics and increased expectations of the surgical population, there is a global need to re-engineer the surgical pathway. There is increasing evidence that utilising the time between contemplation of surgery and admitting for surgery to optimise medical, physical, and psychological health through lifestyle and medical preparatory interventions can improve surgical outcomes. This time needs to be embedded into the surgical pathway and ‘preparation lists’ provide the ideal opportunity to implement the necessary interventions. None of the authors has a direct conflict of interest to declare. DAS is the Director of the Centre for Perioperative Care (CPOC). DNL has received unrestricted research funding for B. Braun and speakers' honoraria from B. Braun, Fresenius Kabi, Baxter Healthcare, and Shire for unrelated work.