Mean Waiting Time Research Articles

Assurance of Timely Access to Breast Cancer Diagnosis and Treatment by a Regional Breast Health Clinic Serving Both Urban and Rural-Remote Communities.

In response to breast cancer diagnostic regional wait times exceeding both national and provincial standards and to symptomatic patient referrals for diagnostic mammography taking longer than abnormal screening mammography referrals, the Rae Fawcett Breast Health Clinic (RFBHC) was opened in 2017 in a mid-sized Canadian hospital serving both urban and rural-remote communities. We investigated whether the RFBHC improved wait times to breast cancer diagnosis, improved compliance with national and provincial breast cancer standards, and decreased the wait time disparity associated with referral source. Statistical analyses of wait time differences were conducted between patients who were diagnosed with breast cancer prior to and after the RFBHC establishment. Study group compliance with national and provincial standards and wait time differences by referral source were also analysed. A survey was administered to assess overall patient experience with the RFBHC and clinic wait times. RFBHC patients had a shorter mean wait to breast cancer diagnosis (24.4 vs. 45.7 days, p ≤ 0.001) and a shorter mean wait to initial breast cancer treatment (49.1 vs. 78.9 days, p ≤ 0.001) than pre-RFBHC patients. After the RFBHC establishment, patients who attended the RFBHC had a shorter mean wait time to breast cancer diagnosis (24.4 vs. 36.9 days, p = 0.005) and to initial treatment (49.1 vs. 73.1 days, p ≤ 0.001) than patients who did not attend the clinic. Compliance with national and provincial breast cancer standards improved after the RFBHC establishment and the wait time disparity between screening mammography referrals and symptomatic patient referrals decreased. Survey results indicate that the RFBHC is meeting patient expectations. We concluded that the establishment of a breast health clinic in a Canadian center serving urban and rural-remote communities improved breast diagnostic services.

Does the American College of Surgeons New Level I Children's Surgery Center Verification Affect Treatment Efficiency and Narcotic Administration in Treating Pediatric Trauma Patients with Femur Fracture?

In 2015, the American College of Surgeons (ACS) created a new hospital improvement program to enhance the performance of pediatric care in US hospitals. The Children's Surgery Verification (CSV) Quality Improvement Program is predicated on the idea that pediatric surgical patients have improved outcomes when treated at children's hospitals with optimal resources. Achieving ACS level I CSV designation at pediatric trauma centers may lead to greater benefits for pediatric trauma patients; however, the specific benefits have yet to be identified. We hypothesize that achieving the additional designation of ACS level I CSV is associated with decreased narcotic use perioperatively and improved efficiency when managing pediatric patients with femur fractures. This study is a retrospective analysis of traumatic pediatric orthopaedic femur fractures treated at a verified level I pediatric trauma center before and after CSV designation (2010 to 2014 vs 2015 to 2019). Efficiency parameters, defined as time from admission to surgery, duration of surgery, and duration of hospital stay, and narcotic administration in oral morphine equivalents (OMEs) were compared. Of 185 traumatic femur fractures analyzed, 80 occurred before meeting ACS level I CSV criteria, and 105 occurred after. Post-CSV, there was a significant decrease in mean wait time from admission to surgery (16.64 hours pre-CSV, 12.52 hours post-CSV [p < 0.01]) and duration of hospital stay (103.49 hours pre-CSV, 71.61 hours post-CSV [p < 0.01]). Narcotic usage was significantly decreased in both the preoperative period (40.61 OMEs pre-CSV, 23.77 OMEs post-CSV [p < 0.01]) and postoperative period (126.67 OMEs pre-CSV, 45.72 OMEs post-CSV [p < 0.01]). Achieving ACS level I CSV designation is associated with increased efficiency and decreased preoperative and postoperative narcotic use when treating pediatric trauma patients.

Time to surgery after radiological diagnosis of brain tumours in Pakistan: A nationwide cross-sectional study.

To investigate waiting times for brain tumour surgery in Pakistan from a nationwide sample and highlight specific affected patient populations. A nationwide study was conducted as part of the Pakistan Brain Tumour Epidemiology Study; data from 32 high-volume neurosurgical centres were collected. The national sample included 2,750 patients. Time to surgery was calculated by the difference in dates recorded for radiological diagnosis and the date of the first surgery. This was further stratified according to demographic factors, histopathological diagnosis, type of surgical procedure performed and survival outcomes. The data of 1,474 patients for time to surgery was available. Patients travelling to public hospitals had significantly longer mean wait times (94.07 (CI: 85.29, 102.84) vs 75.14 (CI: 54.72, 95.56) days, p<0.001). Significant differences were seen between patients of various age groups, as adolescents (116.63 (CI: 65.27, 167.98) days) and young adults (103.34 (CI: 85.96, 120.72) days) had higher waiting times compared to middle-aged (72.44 (CI: 61.26, 83.61) days) and older (48.58 (CI: 31.17, 65.98) days) adults. No difference was seen between the genders. A significantly longer time to surgery was observed for middle- and lower-socioeconomic class patients. Those undergoing gross total resection of the tumour had significantly (p<0.001) longer waiting times for surgery when compared to STR (sub-total resection), biopsy, and CSF-diversion procedures, for all tumour types. Patients diagnosed with meningioma had the most prolonged waiting periods (106 (CI: 76, 95) days). Gliomas had a mean waiting period of 88 (CI: 73, 103) days across the country. Low-grade gliomas had significantly (p=0.031) longer mean waiting times (99.73 (CI: 61.91, 127.36) days) in comparison to high-grade gliomas (70.13 (CI: 43.39, 89.69 ) days). A significant difference was seen between waiting times for patients who survived surgical procedures for a brain tumour on the most recent follow-up and those who had expired (91.87 (CI: 79, 107.74) vs 77.41 (CI: 59.90, 94.91) days, p<0.001). Prolonged delays to surgery are a significant barrier within low-and-middle-income countries, leading to adverse outcomes for patients. Patients undergoing brain tumour surgery at public hospitals from lower or middle SES and electing for gross resections were more likely to have longer delays.

The Impact of COVID-19 on the Diagnosis and Treatment of Lung Cancer over a 2-Year Period at a Canadian Academic Center.

We have recently reported a 35% drop in new lung cancer diagnoses and a 64% drop in lung cancer surgeries during the first year of the pandemic. The target population was divided into three cohorts: pre-COVID-19 (2019), first year of COVID-19 (2020), and second year of COVID-19 (2021). The number of new lung cancer diagnoses during the second year of the pandemic increased by 75%, with more than 50% being in the advanced/metastatic stage. There was a significant increase in cases with multiple extrathoracic sites of metastases during the pandemic. During the first year of the pandemic, significantly more patients were treated with radiosurgery compared to the pre-COVID-19 year. During the second year, the number of radiosurgery and surgical cases returned to pre-COVID-19 levels. No significant changes were observed in systemic chemotherapy and targeted therapy. No statistical difference was identified in the mean wait time for diagnosis and treatment during the three years of observation. However, the wait time for surgery was prolonged compared to the pre-COVID-19 cohort. The significant drop in new diagnoses of lung cancer during the first year of the pandemic was followed by an almost two-fold increase in the second year, with the increased rate of metastatic disease with multiple extra-thoracic site metastases. Limited access to surgery resulted in the more frequent use of radiosurgery.

P061 RAPID-OSA Study: Remote ApneaLink Providing Immediate Diagnosis of Obstructive Sleep Apnoea

Abstract Introduction In-laboratory polysomnography (PSG) is the gold standard for diagnosis of obstructive sleep apnea. However, studies showed portable sleep monitoring devices can reliably substitute PSG in patients with a high pre-test probability of moderate-to-severe OSA. In this prospective study, we assessed utility of ApneaLink for diagnosis of OSA in patients living in rural and remote QLD. Method Thirty-five patients, living in rural and remote QLD were included in the study. ApneaLink device with clear instructions was sent to patients via registered post for being worn for a single typical night. Results were analysed and patients were reviewed post study. Progress to date The study population included thirty five patients (58.8%) male with a mean age of 53.2 years old and median body mass index of 36 kg/m2. The mean time between receiving referral to concluding ApneaLink study was 56 days. This is statistically significant compared to our previous experience in 2017 with mean wait time of 153 days for in-laboratory sleep study (p-value 0.0001). There was significant reduction in expenses in patients underwent level three sleep study compared to PSG. Total postage cost of our study was 1107 Aud with each AL device price of 350$ while in-laboratory study costs 2338$ per night. Conclusion AL has shown substantial cost effectiveness in diagnosis of OSA in patients with uncomplicated moderate to high pre-test probability by eliminating travel cost and reducing in-laboratory sleep study requirement. Full results to follow.

Reducing Wait Times for Radiology Exams Around Holiday Periods: A Monte Carlo Simulation.

Reducing patient wait times is a key operational goal and impacts patient outcomes. The purpose of this study is to explore the effects of different radiology scheduling strategies on exam wait times before and after holiday periods at an outpatient imaging facility using computer simulation.An idealized Monte Carlo simulation of exam scheduling at an outpatient imaging facility was developed based on the actual distribution of scheduled exams at outpatient radiology sites at a tertiary care medical center. Using this simulation, we examined three scheduling strategies: (1) no scheduling modifications, (2) increase imaging capacity before or after the holiday (i.e. increase facility hours), and (3) use a novel rolling release scheduling paradigm. In the third scenario, a fraction of exam slots are blocked to long-term follow-up exams and made available only closer to the exam date, thereby preventing long-term follow-up exams from filling the schedule and ensuring slots are available for non-follow-up exams. We examined the effect of these three scenarios on utilization and wait times, which we defined as the time from order placement to exam completion, during and after the holiday period.The baseline mean wait time for non-follow-up exams was 5.4days in our simulation. When no scheduling modifications were made, there was a significant increase in wait times in the week preceding the holiday when compared to baseline (10.0days vs 5.4days, p < 0.01). Wait times remained elevated for 4weeks following the holiday. Increasing imaging capacity during the holiday and post-holiday period by 20% reduced wait times by only 6.2% (9.38days vs 10.0days, p < 0.01). Increasing capacity by 50% resulted in a 7.1% reduction in wait times (9.28days, p < 0.01), and increasing capacity by 100% resulted in a 13% reduction in wait times (8.75days, p < 0.01). In comparison, using a rolling release model produced a reduction in peak wait times equivalent to doubling capacity (8.76days, p < 0.01) when 45% of slots were reserved. Improvements in wait times persisted even when rolling release was limited to the 3weeks preceding or 1week following the holiday period. Releasing slots on a rolling basis did not significantly decrease utilization or increase wait times for long-term follow-up exams except in extreme scenarios where 80% or more of slots were reserved for non-follow-up exams.A rolling release scheduling paradigm can significantly reduce wait time fluctuations around holiday periods without requiring additional capacity or impacting utilization.

An Asymmetric Polling-Based Optimization Model in a Dynamic Order Picking System

The timeliness of order deliveries seriously impacts customers’ evaluation of logistics services and, hence, has increasingly received attention. Due to the diverse and large quantities of orders under the background of electronic commerce, how to pick orders efficiently while also adapting these features has become one of the most challenging problems for distribution centers. However, previous studies have not accounted for the differences in the stochastic characteristics of order generation, which may lead to asymmetric optimization problems. With this in mind, a new asymmetric polling-based model that assumes the varying stochastic characteristics to analyze such order picking systems is put forward. In addition, two important indicators of the system, mean queue length (MQL) and mean waiting time (MWT), are derived by using probability-generating functions and the embedded Markov chain. Then, simulation experiments and a comparison of the numerical and theoretical results are conducted, showing the usefulness and practicalities of the proposed model. Finally, the paper discusses the characteristics of the novel order picking system and the influence of the MQL and MWT on it.

Cost-Effectiveness of a New Outpatient Pulmonology Care Model Based on Physician-to-Physician Electronic Consultation.

This study assesses the impact of an electronic physician-to-physician consultation program on the waiting list and the costs of a Pulmonology Unit. A prepost intervention study was conducted after a new ambulatory pulmonary care protocol was implemented and the capacity of the unit was adopted. In the new model, physicians at all levels of healthcare send electronic consultations to specialists. In the preintervention year (2019), the Unit of Pulmonology attended 7,055 consultations (466 e-consultations and 6,589 first face-to-face visits), which decreased to 6,157 (3,934 e-consultations and 2,223 first face-to-face visits; 12.7% reduction) in the postintervention year (all were e-consultations). The mean wait time for the first appointment was 25.7 days in 2019 versus 3.2 days in 2021 (p < 0.001). In total, 43.5% of cases were solved via physician-to-physiciane-consultation. A total of 2,223 patients needed a face-to-face visit, with a mean wait time of 7.5 days. The mean of patients in the waiting listing decreased from 450.8 in 2019 to 44.8 in 2021 (90% reduction). The annual time devoted to e-consultations and first face-to-face visits following an e-consultation diminished significantly after the intervention (1,724 hours versus 2,312.8; 25.4% reduction). Each query solved via e-consultation represented a saving of €652.8, resulting in a total annual saving of €827,062. Physician-to-physiciane-consultations reduce waiting times, improve access of complex patients to specialty care, and ensure that cases are managed at the appropriate level. E-consultation reduces costs, which benefits both, society and the healthcare system.

Effect of socioeconomic status on wait times for patients undergoing treatment for laryngeal conditions in a universal healthcare system.

As one of the world's only fully publicly administered, universal healthcare systems, Canada intends to provide equitable access to services for all patients. Socioeconomic status (SES) can affect treatment wait times with implications on health outcomes; however, this has not been evaluated in the setting of laryngeal disease, which incorporates urgent and elective conditions, in a universal healthcare system. This study aims to identify whether SES-affected treatment wait times for laryngeal therapies in this system. A retrospective review was conducted on a cohort of patients with laryngeal disease at an academic, tertiary center who underwent laryngeal surgery over a three-year period. Data retrieved through medical records; surgical and voice therapy wait times were normalized to each practitioner's average wait time for respective diagnostic categories. Income was used to assess SES and was derived from Statistics Canada census information based on patient postal codes. Data analysis identified 578 patients (59% male). Mean wait time to surgery for all conditions was 123.5 (95% confidence interval 113.1-133.9) days. Analysis of variance analysis found no difference in wait times between different SES groups (p= .28), regardless of laryngeal disease category. Patients with cancer or airway obstruction had shorter wait times compared with benign conditions (p< .0001). SES did not affect treatment wait times for laryngeal therapies in a universal healthcare system. Wait times were shorter for oncologic and obstructive conditions compared with benign conditions, reflecting an ability to accommodate clinical needs without impacting care access at the detriment of different SES statuses. 4.

Addressing spatial service provision equity for pooled ride‐hailing services through rebalancing

AbstractRide‐hailing services have the potential to play a major role within future transport systems. While the operation as well as environmental, social and economic consequences are research subjects, the focus in the literature lies on system efficiency and profitability. In this study, vehicle relocation strategies are investigated with respect to service provision equity using an agent‐based simulation approach. The aim is to identify ways of operation that support social fairness while maintaining the profitability and effectiveness of the service. The results show that a typical demand‐anticipatory relocation strategy leads to an imbalance in the spatial distribution of mean wait times for the use case of Berlin. This can be significantly improved by applying different relocation strategies. As a consequence, the overall demand for the system rises while the ratio of empty vehicle kilometres increases slightly.

171. DELAYED DIAGNOSIS OF EOSINOPHILIC ESOPHAGITIS IN THOSE PRESENTING TO THE EMERGENCY DEPARTMENT WITH FOOD BOLUS IMPACTION

Abstract Food bolus impaction can be a manifestation of chronic untreated inflammation in those with underlying eosinophilic esophagitis (EoE). The eosinophil predominant inflammation of the esophagus is associated with a higher prevalence of fibrosis when it remains undetected and untreated. Non-malignant food bolus impaction is strongly associated with an underlying diagnosis of EoE, but outside of gastroenterology and other esophageal interested specialists there remains poor understanding of how to diagnose and manage this condition. We conducted a retrospective study of patients presenting to a tertiary emergency unit with esophageal food bolus impaction between November 2018 and May 2021. Electronic attendance records and the endoscopy database were examined to determine the associations between demographics, comorbidities, endoscopic findings, biopsy findings and follow up. We also evaluated the effect of the pandemic on food bolus management with statistical analysis undertaken using IBM SPSS software. Of the 938 patients who presented to the emergency department with food bolus impaction, 83.6% were sent home with no follow up. Only 7.2% went on to have an endoscopy. In those with macroscopic evidence of inflammation, only 35.8% of patients had the correct number of biopsies taken to establish a histological cause for their symptoms. 1.6% of patients demonstrated histological evidence of EoE, of whom 80% were male and 20% female. The COVID-19 lockdown did not negatively impact access to endoscopy with mean wait time improving from 121-days prior to lockdown compared to 69-days during lockdown, p &amp;lt; 0.01. Our findings highlight significant shortcomings in the management of those presenting emergently with food bolus impaction and possible undiagnosed EoE. There remains a need for clear management pathways to aid risk-stratification, discharge planning and endoscopic practices in the diagnosis of EoE. We therefore propose an algorithm for food bolus management to facilitate early endoscopy, effective diagnosis, and appropriate follow-up, ensuring optimal management for patients with non-malignant dysphagia requiring emergency admission for resolution of food impaction.

Alpha Power Exponentiated New Weibull-Pareto Distribution: Its Properties and Applications

In this paper, a new five-parameter model called alpha power exponentiated new Weibull-Pareto distribution is introduced based on a new developing technique. We derived some properties relating to the proposed distribution, including moments, moment generating function, quantile function, mean residual life and mean waiting time, and order statistics of the new model. The model parameters are estimated using the maximum likelihood method. Some simulation studies are performed to investigate the effectiveness of the estimates. Finally, we used three real-life data sets to show the flexibility of the introduced distribution.

"Don't Just Study our Distress, Do Something": Implementing and Evaluating a Modified Stepped-Care Model for Health Care Worker Mental Health During the COVID-19 Pandemic.

ObjectiveThroughout the COVID-19 pandemic, there have been concerns about the mental health of health care workers (HCW). Although numerous studies have investigated the level of distress among HCW, few studies have explored programs to improve their mental well-being. In this paper, we describe the implementation and evaluation of a program to support the mental health of HCW at University Health Network (UHN), Canada's largest healthcare network.MethodsUsing a quality improvement approach, we conducted a needs assessment and then created and evaluated a modified stepped-care model to address HCW mental health during the pandemic. This included: online resources focused on psychoeducation and self-management, access to online support and psychotherapeutic groups, and self-referral for individual care from a psychologist or psychiatrist. We used ongoing mixed-methods evaluation, combining quantitative and qualitative analysis, to improve program quality.ResultsThe program is ongoing, running continuously throughout the pandemic. We present data up to November 30, 2021. There were over 12,000 hits to the UHN's COVID mental health intranet web page, which included self-management resources and information on group support. One hundred and sixty-six people self-referred for individual psychological or psychiatric care. The mean wait time from referral to initial appointment was 5.4 days, with an average of seven appointments for each service user. The majority had moderate to severe symptoms of depression and anxiety at referral, with over 20% expressing thoughts of self-harm or suicide. Post-care user feedback, collected through self-report surveys and semistructured interviews, indicated that the program is effective and valued.ConclusionsDevelopment of a high-quality internal mental health support for HCW program is feasible, effective, and highly valued. By using early and frequent feedback from multiple perspectives and stakeholders to address demand and implement changes responsively, the program was adjusted to meet HCW mental health needs as the pandemic evolved.

Waiting time for Mohs Micrographic Surgery and the associated increase in lesion size of basal cell carcinoma

The first-line treatment for basal cell carcinoma (BCC) involved either surgical excision (SE) or Mohs micrographic surgery (MMS). The current waiting time for MMS and whether this is associated with worsening of outcome is unknown. We aim to look at the waiting time for MMS upon review at the Outpatient Specialist Dermatology Clinic and the increase in lesion size during this time period. A retrospective analysis of all patients who underwent MMS for biopsy-proven BCC over a duration of 5 years was performed. Variables analysed included patient age, sex, location, histologic subtype, lesion size at initial presentation, lesion size during MMS, defect size following MMS, waiting time for MMS, and projected defect size if lesions were treated with SE at earlier time point. A total of 233 patients were included in the final analysis. The mean wait time between referral to MMS was 215.8±125.7 days. The mean maximum diameter of lesions was 9.34±5.23 mm at referral for MMS and 11.91±6.60 mm at presentation for MMS, hence an increase of 3.01±3.03 mm (p=0.001, paired t-test), which equates to 1.41±0.42 times increase. The mean maximum diameter of the actual defect size post-MMS was 18.03±9.45mm, while the projected diameter of defect post SE was 15.29±5.71 mm, hence, smaller by 3.27±5.51 mm (p=0.001, paired t-test) compared with actual defect size post-MMS. This study highlights that the lesion grows significantly during the long wait for MMS. Hence, an increase in capacity for MMS is essential to reduce the waiting time for surgery which could lead to a defect which is easier to reconstruct with better outcome for patients.

Surgical wait times and socioeconomic status in a public healthcare system: a retrospective analysis

BackgroundOne aim of publicly-funded health care systems is to provide equitable access to care irrespective of ability to pay. At the same time, differences in socioeconomic status (SES) are associated with health outcomes and access to care, including waiting times for surgery. In public systems where both high- and low-SES patients use the same resources, low-SES patients may be adversely impacted in surgical waiting times. The purpose of this study was to determine whether a publicly-funded health system can provide equitable access to surgical care across socioeconomic status.MethodsPatient-level records were obtained from a comprehensive provincially-administered surgical wait time database, encompassing years 2006–2015 and 98% of Ontario hospitals. Patient SES was determined by linking postal code with the Material and Social Deprivation Index. Surgical waiting times (time in days between decision to treat and surgery) accounted for patient-initiated delays in treatment, and regression analysis considered age, SES, rurality, sex, priority level for surgical urgency (assigned by surgeons), surgical subspecialty, number of visits, and procedure year.ResultsFor the 4,253,305 surgical episodes, the mean wait time was 62.3 (SD 75.4) days. Repeated measures least squares regression analysis showed the least deprived SES quintile waited 3 days longer than the most deprived quintile. Wait times dropped in the initial study period but then increased. The proportion of procedures exceeding wait time access targets remained low at 11–13%.ConclusionsThe least deprived SES quintile waited the longest, although the absolute difference was small. This study demonstrates that publicly-funded healthcare systems can provide equitable access to surgical care across SES.

P249 Analysis of the performance of a newly developed axial spondyloarthritis clinic at a district general hospital

Background/AimsTraditionally, patients with ankylosing spondylitis (AS) and axial spondyloarthritis (axSpA) have been managed in general rheumatology clinics at district general hospitals, which can potentially lead to delays in diagnosis or treatment. In order to improve the service, a fortnightly axSpA clinic was set up at West Suffolk Hospital, with appointments with either a consultant or nurse specialist.MethodsA retrospective case note review was performed for patients diagnosed with axSpA prior to the establishment of the axSpA clinic in April 2019 (comparator group), who were subsequently followed-up in the axSpA clinic. The ‘active group’ comprised patients referred to the clinic with suspected axSpA from May 2019 to December 2020. The performance analysis looked at time from GP referral to outpatient appointment (OPA), time from OPA to MRI examination, time from MRI scan to follow-up appointment and time to biologic disease-modifying anti-rheumatic drug (bDMARD) therapy. Statistical analysis was performed using unpaired t-tests.ResultsFrom December 2013 to April 2019, 31 patients were identified with an axSpA diagnosis (comparator group), and 65 patients were identified post-audit (active group). The mean time from referral to initial OPA was unchanged between the two groups, at 37 days. While the time from OPA to MRI scan was significantly shorter prior to set-up of the axSpA clinic (34.9 vs. 76.7 days; p = 0.0014), at least nine patients had delayed MRI owing to COVID-19. Excluding these patients from the analysis, the mean wait time from MRI scan in the active group reduced to 35.2 days, which was not statistically different from the comparator group (p = 0.9600). Time from MRI to follow-up OPA and time from a patient meeting the criteria for bDMARD therapy to first prescription of bDMARD reduced following set-up of the axSpA clinic, although differences were not significant (93.1 vs. 50.0 days; p = 0.1400 and 35.3 vs. 21.0 days; p = 0.0510, respectively). Time from first OPA to bDMARD therapy prescription reduced significantly (288.4 vs. 116.7 days; p < 0.0500).ConclusionThe set-up of the axSpA clinic did not make any difference to the early part of the axSpA pathway (the diagnostic phase); however, there was a notable difference for follow-up times and starting treatment after the diagnosis had been made, which most likely reflects the importance of the role of a nurse specialist in the clinic.Disclosure L.A. Newdick: None. M.P. Sykes: None.

Quality of life during the wait for ruptured anterior cruciate ligament reconstruction: a randomized controlled trial.

Background:There is a lack of prospective evidence to guide surgeons when making recommendations about the appropriate timing of surgical intervention for ruptured anterior cruciate ligament (ACL), activity modifications to reduce the risk of secondary injury before surgery, and the short- and long-term risks associated with delayed ACL reconstruction. This study aimed to determine whether longer wait times are associated with a prolonged decrease in quality of life and an increased incidence of secondary joint injury after ACL rupture.Methods:We recruited 53 patients who presented between 2013 and 2017 at a single sports medicine minor injury clinic with a suspected acute ACL rupture, based on clinical examination; ACL rupture was confirmed on magnetic resonance imaging. Patients were randomly allocated to undergo early reconstruction (< 12 wk after injury) or reconstruction after a regular wait time (≥ 12 wk). We compared scores on the ACL quality of life measure (ACL-QOL) and the incidence of secondary knee injury at baseline and at surgery between the 2 groups. Participants also completed the Tegner scale (level of activity) at the time of consent and within 7 days before surgery.Results:Twenty-eight patients were randomly assigned to the early surgery group and 25 patients to the regular wait time group. There was no difference in mean age between the 2 groups. There were no between-group differences in mean ACL-QOL score at the time of injury (28.5 [standard deviation (SD) 12.5] v. 28.5 [SD 12.6]) or at surgery (34.9 [SD 17.5] v. 38.0 [SD 17.5]). The mean wait time was significantly longer in the regular wait time group than in the early surgery group (29.6 wk [SD 13.2 wk] v. 10.6 wk [SD 5.1 wk], p = 0.001). In both groups, Tegner scale scores were significantly lower after than before ACL rupture (p < 0.001) and remained low while patients waited for surgery. There were no between-group differences in the incidence of chondral or meniscal injury at surgery, although the study was not adequately powered to draw any statistical conclusions.Conclusion:Wait time for ACL reconstruction may affect patients’ quality of life, as it remained diminished for a longer period when surgery was delayed. A low activity level during the waiting period was observed in both groups; this low activity level may be one reason why no between-group differences in the incidence of secondary injury were observed. The findings suggest that patients with a limited activity level during the waiting period have a low risk of secondary injuries.

Impact of wait times on late postprocedural mortality after successful transcatheter aortic valve replacement

Wait times are associated with mortality on waiting list for transcatheter aortic valve replacement (TAVR). Whether longer wait times are associated with long term mortality after successful TAVR remains unassessed. Consecutive patients successfully treated with elective TAVR in our center between January 2013 and August 2019 were included. The primary end point was one-year all-cause mortality. TAVR wait times were defined as the interval from referral date for valve replacement to the date of TAVR procedure. A total of 383 patients were included with a mean wait time of 144.2 ± 83.87 days. Death occurred in 55 patients (14.4%) at one year. Increased wait times were independently associated with a relative increase of 1-year mortality by 2% per week after referral (Adjusted Hazard Ratio 1.02 [1.002–1.04]; p = 0.02) for TAVR. Chronic kidney disease, left ventricular ejection fraction ≤ 30%, access site and STS score were other independent correlates of 1-year mortality. Our study shows that wait times are relatively long in routine practice and associated with increased 1-year mortality after successful TAVR. Such findings underscore the need of strategies to minimize delays in access to TAVR.

The Impact of the New UNOS Allocation System on Heart Kidney Recipients

Purpose In October 2018, the United Network for Organ Sharing (UNOS) updated the allocation system for adult heart transplants (HT). While data suggests equivalent outcomes among HT recipients before and after this change, its effect on heart kidney transplants (HKT) has not been investigated. Methods A retrospective analysis of adults in the UNOS database undergoing HT and HKT from 2015 - 2021 was performed. The population was divided into a before and after allocation change group. Univariate t-test and chi-square tests were used to compare the cohorts. Our primary outcome was the effect of this change on patient survival. We also examined the use of mechanical support prior to transplantation (Tx). Results 17,684 patients were included; 9,805 transplanted before the change and 7,879 after. Mean wait time for HT decreased from 255 to 187 days following change in allocation system (p < 0.001). HT patients in the prior system were more likely to have a left ventricular assist device (LVAD) before Tx than HT patients in the new system (51.3% v 35.7%, p < 0.001). Use of intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenator (ECMO) was higher in the group transplanted after the allocation change (IABP: 26.8% v 7.4%, p < 0.001 and ECMO: 4.9% v 0.8%, p < 0.001). The proportion of HKT increased following the change (8.5% vs 5.6%). Pre-management of HKT mirrored that seen in HT with more HKT recipients on LVAD support before than after the change (41.7% v 29.9%, p < 0.001). Utilization of IABP and ECMO was also higher in the group transplanted after the allocation change (IABP: 26.2% v 9.8%, p < 0.001 and ECMO: 5.8% v 1.3%, p < 0.001). Under the new system, survival was lower among HKT recipients compared to only HT recipients (mean 382 days vs 446 days); meanwhile there was no difference in survival between HKT and HT alone in the old system. Conclusion Following the change in the allocation system, a higher proportion of patients receiving HT and HKT were on ECMO and IABP support pre-Tx, while less patients were on LVAD support pre-Tx. We observed a decrease in survival among HKT recipients after the change. This may be due to higher acuity of the HKT group under the new system, or may demonstrate an impact of temporary mechanical support on survival. More detailed analysis is needed to determine factors that are influencing survival in this cohort. In October 2018, the United Network for Organ Sharing (UNOS) updated the allocation system for adult heart transplants (HT). While data suggests equivalent outcomes among HT recipients before and after this change, its effect on heart kidney transplants (HKT) has not been investigated. A retrospective analysis of adults in the UNOS database undergoing HT and HKT from 2015 - 2021 was performed. The population was divided into a before and after allocation change group. Univariate t-test and chi-square tests were used to compare the cohorts. Our primary outcome was the effect of this change on patient survival. We also examined the use of mechanical support prior to transplantation (Tx). 17,684 patients were included; 9,805 transplanted before the change and 7,879 after. Mean wait time for HT decreased from 255 to 187 days following change in allocation system (p < 0.001). HT patients in the prior system were more likely to have a left ventricular assist device (LVAD) before Tx than HT patients in the new system (51.3% v 35.7%, p < 0.001). Use of intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenator (ECMO) was higher in the group transplanted after the allocation change (IABP: 26.8% v 7.4%, p < 0.001 and ECMO: 4.9% v 0.8%, p < 0.001). The proportion of HKT increased following the change (8.5% vs 5.6%). Pre-management of HKT mirrored that seen in HT with more HKT recipients on LVAD support before than after the change (41.7% v 29.9%, p < 0.001). Utilization of IABP and ECMO was also higher in the group transplanted after the allocation change (IABP: 26.2% v 9.8%, p < 0.001 and ECMO: 5.8% v 1.3%, p < 0.001). Under the new system, survival was lower among HKT recipients compared to only HT recipients (mean 382 days vs 446 days); meanwhile there was no difference in survival between HKT and HT alone in the old system. Following the change in the allocation system, a higher proportion of patients receiving HT and HKT were on ECMO and IABP support pre-Tx, while less patients were on LVAD support pre-Tx. We observed a decrease in survival among HKT recipients after the change. This may be due to higher acuity of the HKT group under the new system, or may demonstrate an impact of temporary mechanical support on survival. More detailed analysis is needed to determine factors that are influencing survival in this cohort.

Dually-enrolled patients choose providers with lower wait times: Budgetary implications for the VHA.

To estimate the effect of wait times on patients' choice of provider and simulate changes in choice of provider due to compliance with VA MISSION Act wait time targets. We use nationwide administrative data (2014-2017) on Veterans who are enrolled in Medicare and the Veterans Health Administration (VHA), the Survey of VHA Enrollees, Area Health Resource Files, and other data provided by the Centers for Medicare & Medicaid Services. We use an instrumental variables approach to identify the effect of VHA wait times on the proportion of total (Medicare and VHA) services that are paid for by the VHA ("reliance"). We exploit shocks to VHA provider supply to isolate supply-driven changes in wait times and estimate the effect on VHA reliance. We control for market and time fixed effects and local demand factors. We use monthly aggregated data on 140 markets (groups of counties). VHA reliance is computed among patients aged 65 years or older who are dually enrolled in VHA and Medicare. VHA wait times and reliance are calculated for multiple specialties: cardiology, gastroenterology, orthopedics, urology, dermatology, and ophthalmology/optometry. A 10% increase in the mean wait time (+2.8 days) reduces VHA reliance by 2.3 percentage points (95% CI: 2.3, 2.7), or 7.9% of the sample mean. This implies that meeting the MISSION Act wait time targets may have multi-billion-dollar budgetary impacts. Effects vary across specialties. For example, a 10% increase in the mean wait time for cardiology services (+2.0 days) reduces reliance by 1.8 percentage points (95% CI: 1.6, 2.1), or 6.3% of the sample mean for cardiology services. Meeting statutory wait time targets may have substantial unforeseen impacts on federal health care spending as patients sort to providers who have lower wait times.