Waits For Surgery Research Articles

Accountability frameworks: A critical evolution in healthcare.

Canadians face prolonged waits for primary care, specialist care, hospital care, elective surgery, and advanced imaging relative to peer countries. A root problem is unclear queue management expectations. If programs have no mandate to provide timely care, the intuitive approach to demand challenges is not to innovate and improve, but to block access, create a queue, and force patients elsewhere. Patient care accountability frameworks define program expectations and accountability zones, clarifying that every patient has an accountable healthcare home and every program has a population (accountability zone). Program accountabilities include timely patient assessment and disposition; budget, space, and nursing care for program patients; and contingency plans for surges and queues. Accountability frameworks are an evolutionary stressor that would drive strategies to expedite appropriate care in the right place, to move patients out of queues into care. This article discusses accountability, accountability frameworks, and accountability strategies to improve system-wide access.

Time to surgery for adolescent idiopathic scoliosis: How long does it take? A multicenter study

Study designRetrospective review of multicentric data. ObjectivesTo estimate the time from initial visit to surgery in adolescent idiopathic scoliosis (AIS) patients and the main reasons for the time to surgery in a multicenter study. MethodsThis retrospective study evaluated 509 patients with AIS from 16 hospitals across six Latin American countries. From each hospital's deformity registry, the following patient data were extracted: demographics, main curve Cobb angle, Lenke Classification at the initial visit and time of surgery, time from indication-for-surgery to surgery, curve progression, Risser skeletal-maturity score and causes for surgical cancelation or delay. Surgeons were asked if they needed to change the original surgical plan due to curve progression. Data also were collected on each hospital's waiting list numbers and mean delay to AIS surgery. Results66.8% of the patients waited over six months and 33.9% over a year. Waiting time was not impacted by the patient's age when surgery first became indicated (p = 0.22) but waiting time did differ between countries (p < 0.001) and hospitals (p < 0.001). Longer time to surgery was significantly associated with increasing magnitude of the Cobb angle through the second year of waiting (p < 0.001). Reported causes for delay were hospital-related (48.4%), economic (47.3%), and logistic (4.2%). Oddly, waiting time for surgery did not correlate with the hospital's reported waiting-list lengths (p = 0.57) ConclusionProlonged waits for AIS surgery are common in Latin America, with rare exceptions. At most centers, patients wait over six months, most commonly for economic and hospital-related reasons. Whether this directly impacts surgical outcomes in Latin America still must be studied.

The Golden Hour of Casualty Care: Rapid Handoff to Surgical Team is Associated With Improved Survival in War-injured US Service Members.

To examine time from injury to initiation of surgical care and association with survival in US military casualties. Although the advantage of trauma care within the "golden hour" after an injury is generally accepted, evidence is scarce. This retrospective, population-based cohort study included US military casualties injured in Afghanistan and Iraq, January 2007 to December 2015, alive at initial request for evacuation with maximum abbreviated injury scale scores ≥2 and documented 30-day survival status after injury. Interventions: (1) handoff alive to the surgical team, and (2) initiation of first surgery were analyzed as time-dependent covariates (elapsed time from injury) using sequential Cox proportional hazards regression to assess how intervention timing might affect mortality. Covariates included age, injury year, and injury severity. Among 5269 patients (median age, 24 years; 97% males; and 68% battle-injured), 728 died within 30 days of injury, 68% within 1 hour, and 90% within 4 hours. Only handoffs within 1 hour of injury and the resultant timely initiation of emergency surgery (adjusted also for prior advanced resuscitative interventions) were significantly associated with reduced 24-hour mortality compared with more delayed surgical care (adjusted hazard ratios: 0.34; 95% CI: 0.14-0.82; P = 0.02; and 0.40; 95% CI: 0.20-0.81; P = 0.01, respectively). In-hospital waits for surgery (mean: 1.1 hours; 95% CI; 1.0-1.2) scarcely contributed ( P = 0.67). Rapid handoff to the surgical team within 1 hour of injury may reduce mortality by 66% in US military casualties. In the subgroup of casualties with indications for emergency surgery, rapid handoff with timely surgical intervention may reduce mortality by 60%. To inform future research and trauma system planning, findings are pivotal.

Prioritization and surgical wait lists: A cross-sectional survey of patient's health-related quality of life

IntroductionIn many countries, there are waits for elective (planned) surgery. In these settings, processes for triaging patients are applied to determine how long patients wait for their surgery. There are very few instances that evaluate the effectiveness of surgical triage processes. MethodsA sample of patients from four acute care hospitals in Vancouver, Canada, completed a number of patient-reported outcomes shortly after being registered on the surgical wait list. Patients’ diagnosis was used to triage and determine their expected wait for surgery. The associations between patient-reported outcomes with surgical triage were measured. ResultsThe mean wait times for participants were similar across wait times categories. Participants whose expected waits for surgery were the longest reported successively lower levels of self-rated health (p < 0.01) and successively higher levels of pain (p < 0.01.) There was no difference in symptoms of anxiety among participants expected to wait the longest. DiscussionThe diagnosis-based system for prioritizing patients found higher levels of pain and lower health status among those expected to wait the longest for their surgery. Screening waiting patients for treatable mental health conditions should be implemented and the process of surgical triage could be redesigned to allow for a broader set of attributes of health to determine how long a patient waits for their elective surgery.

Addressing the mental health of Canadians waiting for elective surgery: a potential positive post-pandemic legacy

The impact of waiting for surgery on the mental health of patients usually receives little attention. Because of the coronavirus disease 2019 (COVID-19) pandemic, the waits for elective surgery have been lengthening, potentially inducing or exacerbating mental health burdens. Provinces' health systems need to provide better support to assess not only patients' physical health, but also their mental health, and provide them with timely access to care based on need. A stepped care approach is needed to mitigate negative mental health effects associated with prolonged waits for elective operations. To provide the best care possible, we need to recognize and address both the physical and mental health problems of our waiting patients.

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

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...

Delayed access to bunion correction surgery

Category: Bunion Introduction/Purpose: Little is known about the effect of delayed access to bunion correction (Hallux Valgus) surgery on patient-reported outcomes. The objective of this study is to measure the association between delayed access to bunion correction surgery and post-operative patient-reported outcomes. Methods: This study prospectively recruited patients to complete pre-operative patient-reported outcomes measuring pain, depression and foot and ankle health. Patients complete the same patient-reported outcomes six months post-operatively. Linear regression models measured outcomes, adjusting for baseline health, age category, sex, comorbidities and socio-economic status. Results: This study included 74 participants, a response rate of 53% among eligible patients. Among participants, 58.9% underwent a Lapidus procedure, the remainder underwent a corrective osteotomy. There was no relationship between post-operative depression and pain scores with duration of wait time, adjusting for patient characteristics. Longer waits for bunion correction surgery, adjusting for other factors, were associated with smaller gains in health in four of the five domains of measurement of foot and ankle health. Conclusion: At the six-month post-operative time point, prolonged wait times were detrimental to foot and ankle outcomes in four of the five domains of the foot and ankle specific PRO. Policies for expediting access for symptomatic hallux valgus are warranted to mitigate poorer long-term outcomes.

Does the wait for lumbar degenerative spinal stenosis surgery have a detrimental effect on patient outcomes? A prospective observational study.

Waits for elective spine surgery are common in Canada. We examined whether a prolonged wait for surgery for lumbar degenerative spinal stenosis was detrimental to outcome. In this prospective observational study, we enrolled 166 consecutive patients referred to our centre for treatment of lumbar degenerative spinal stenosis between 2006 and 2010. Outcome measures were assessed at referral, preoperatively and until 24 months postoperatively. Primary outcome measures were the physical and mental component summary scores of the 36-Item Short-Form Health Survey and the Oswestry Disability Index. Secondary outcome measures included the symptom severity scale of the Zurich Claudication Questionnaire, a numeric rating scale for back and leg pain, and patient satisfaction with treatment. Wait time was defined as the time from referral to surgery. The follow-up rate at 2 years was 85%. The median wait time was 349 days. All health-related quality of life measures deteriorated during the waiting period, but there was no significant correlation between wait time and magnitude of the change in outcome measure. At 6 months postoperatively, the Pearson correlation was significantly positive between wait time and change in disability (r = 0.223), Zurich Claudication Questionnaire score (r = 0.2) and leg pain score (r = 0.221). At 12 months, the correlation remained significant for change in disability (r = 0.205) and was significant for change in mental well-being (r = -0.224). At 12 months, patients with a shorter wait (≤ 12 months) showed greater improvement in mental well-being (mean difference in change [and 95% confidence interval (CI)] 5.7 [1.4-9.9]) and decrease in disability (-9.3 [95% CI -15.1 to -3.6]) and leg pain (-1.6 [95% CI -3.0 to -0.3]). There were no statistically significant differences in outcome or patient satisfaction with treatment between those with shorter and longer waits at 24 months. Patients awaiting spinal surgery experienced deterioration in health-related quality of life irrespective of the length of wait time. However, longer waits were associated with a delay in recovery during the first year after surgery.

Patient Satisfaction with Wait-Times for Breast Cancer Surgery in Newfoundland and Labrador

Do shorter waits for breast cancer surgery lead to greater wait-related patient satisfaction? Using survey and cancer clinic chart data of 99 patients with breast cancer from Newfoundland and Labrador, we found that median wait-time from first visit to a surgeon to surgery was 22.0 days and 87% were satisfied with their wait-time. Wait-related satisfaction was not associated with the length of wait but rather with the stage, severity of treatment, wait-time for a diagnosis and satisfaction with diagnosis-related wait. These findings highlight the importance of an early and timely diagnosis in patients' perceptions of breast cancer care wait-times.

Breast Cancer among Women Living in Poverty: Better Care in Canada than in the United States.

This historical study estimated the protective effects of a universally accessible, single-payer health care system versus a multi-payer system that leaves many uninsured or underinsured by comparing breast cancer care of women living in high poverty neighborhoods in Ontario or California between 1996 and 2011. Women in Canada experienced better care particularly as compared to women who were inadequately insured in the United States. Women in Canada were diagnosed earlier (rate ratio [RR] = 1.12) and enjoyed better access to breast conserving surgery (RR = 1.48), radiation (RR = 1.60) and hormone therapies (RR = 1.78). Women living in high poverty Canadian neighborhoods even experienced shorter waits for surgery (RR = 0.58) and radiation therapy (RR = 0.44) than did such women in the US. Consequently, women in Canada were much more likely to survive longer. Regression analyses indicated that health insurance could explain most of the better care and better outcomes in Canada. Over this study's 15-year timeframe 31,500 late diagnoses, 94,500 sub-optimum treatment plans and 103,500 early deaths were estimated in high poverty US neighborhoods due to relatively inadequate health insurance coverage. Implications for social work practice, including advocacy for future reforms of US health care are discussed.

Dedicated operating room for emergency surgery improves access and efficiency

Scheduling emergency cases among elective surgeries often results in prolonged waits for emergency surgery and delays or cancellation of elective cases. We evaluated the benefits of a dedicated operating room (OR) for emergency procedures available to all surgical services at a large children's hospital. We compared a 6-month period (January 2009 to June 2009) preimplementation with a 6-month period (January 2010 to June 2010) postimplementation of a dedicated OR. We evaluated OR use, wait times, percentage of cases done within and outside of access targets, off-hours surgery, cancellations, overruns and length of stay. Preimplementation, 1069 of the 5500 surgeries performed were emergency cases. Postimplementation, 1084 of the 5358 surgeries performed were emergency cases. Overall use of the dedicated OR was 53% (standard deviation 25%) postimplementation. Excluding outliers, the average wait time for priority 3 emergency patients decreased from 11 hours 8 minutes to 10 hours 5 minutes (p = 0.004). An increased proportion of priority 3 patients, from 52% to 58%, received surgery within 12 hours (p = 0.020). There was a 9% decrease in the proportion of priority 3 cases completed during the evening and night (p < 0.001). The elective surgical schedule benefited from the dedicated OR, with a significant decrease in cancellations (1.5% v. 0.7%, p < 0.001) and an accumulated decrease of 5211 minutes in overrun minutes in elective rooms. The average hospital stay after emergency surgery decreased from 16.0 days to 14.7 days (p = 0.12) following implementation of the dedicated OR. A dedicated OR for emergency cases improved quality of care by decreasing cancellations and overruns in elective rooms and increasing the proportion of priority 3 patients who accessed care within the targeted time.

Waiting for children’s surgery in Canada: the Canadian Paediatric Surgical Wait Times project

In addition to possibly prolonged suffering and anxiety, extended waits for children's surgery beyond critical developmental periods has potential for lifelong impact. The goal of this study was to determine the duration of waits for surgery for children and youth at Canadian paediatric academic health sciences centres using clinically-derived access targets (i.e., the maximum acceptable waiting periods for completion of specific types of surgery) as used in this Canadian Paediatric Surgical Wait Times project. We prospectively applied standardized wait-time targets for surgery, created by nominal-group consensus expert panels, to pediatric patients at children's health sciences centres across Canada with decision-to-treat dates of Sept. 1, 2007 or later. From Jan. 1 to Dec. 30, 2009, patients' actual wait times were compared with their target wait times to determine the percentage of patients receiving surgery after the target waiting period. Overall, 27% of pediatric patients from across Canada (17,411 of 64,012) received their surgery after their standardized target waiting period. Dentistry, ophthalmology, plastic surgery and cancer surgery showed the highest percentages of surgeries completed past target. Many children wait too long for surgery in Canada. Specific attention is required, in particular, in dentistry, ophthalmology, plastic surgery and cancer care, to address children's wait times for surgery. Improved access may be realized with use of national wait-time targets.

“Liberating the NHS” — Another Attempt to Implement Market Forces in English Health Care

Like so many recent British governments, the new Conservative–Liberal Democrat coalition government is making structural changes to the National Health Service (NHS) in England. Such changes are being made despite campaign promises by the Conservative Party that it would not reorganize the NHS and despite a decade of steady improvements: for example, waits for elective surgery have largely disappeared, people with suspected cancers are now seen by specialists within 2 weeks, and survival rates among patients hospitalized in critical care units have increased by more than 2% per year. Although it supports the founding principles of the NHS — a . . .

Time to talk? Patient experiences of waiting for clinical management of knee injuries

Background:People with knee problems face long waits for elective surgery in many parts of the world. However, there is little evidence about the impact of delays in such treatment, especially...

Sicko Statistics: Michael Moore and L'Ècole de Paris

Sicko Statistics: Michael Moore and L'Ècole de Paris

Willingness of patients to change surgeons for a shorter waiting time for joint arthroplasty

To improve access to care, many jurisdictions have proposed waiting-time benchmarks and guarantees. We assessed the willingness of patients to consider changing their surgeon to one with a shorter waiting time for arthroplasty. We mailed a questionnaire to 2 random samples of patients who either were awaiting hip or knee replacement arthroplasty or had had one of these procedures within the preceding 3-12 months. We used logistic regression to assess the determinants of patients' likelihood to consider changing surgeons. Of 1200 responses from a sample of 2000, 557 (46%) were from patients awaiting surgery and 643 (54%) were from people who had undergone surgery. The mean age of respondents was 69.9 years (standard deviation 10.8), and 682 (57%) were women. The median waiting time for surgery was 8 months. Overall, 753 (63%) of the patients were unlikely to consider changing surgeons. Increased likelihood of changing surgeons was associated with male sex (adjusted odds ratio [OR] 1.49, 95% confidence interval [CI] 1.10-2.02), a high school education or higher (OR 1.73, 95% CI 1.15-2.62) and having already undergone surgery (OR 1.71, 95% CI 1.19-2.46). Decreased likelihood was associated with preference for a particular surgeon before referral (OR 0.57, 95% CI 0.42-0.79), a better score on the EuroQol (EQ-5D) index (a measure of health-related quality of life) (OR 0.39, 95% CI 0.24-0.66), perception that the waiting time to see the surgeon was acceptable (OR 0.50, 95% CI 0.36-0.70), perception that the waiting time to surgery was acceptable (OR 0.62, 95% CI 0.43-0.91) and perceived fairness of treatment (OR 0.53, 95% CI 0.36-0.78). Despite long waits for surgery, most patients, if given the choice, would be unlikely to change their surgeon to one with a shorter waiting time.

Factors associated with time to laparoscopic cholecystectomy for acute cholecystitis

To determine patient and process of care factors associated with performance of timely laparoscopic cholecystectomy for acute cholecystitis. A retrospective medical record review of 88 consecutive patients with acute cholecystitis was conducted. Data collected included demographic data, co-morbidities, symptoms and physical findings at presentation, laboratory and radiological investigations, length of stay, complications, and admission service (medical or surgical). Patients not undergoing cholecystectomy during this hospitalization were excluded from analysis. Hierarchical generalized linear models were constructed to assess the association of pre-operative diagnostic procedures, presenting signs, and admitting service with time to surgery. Seventy cases met inclusion and exclusion criteria, among which 12 were admitted to the medical service and 58 to the surgical service. Mean +/- SD time to surgery was 39.3 +/- 43 h, with 87% of operations performed within 72 h of hospital arrival. In the adjusted models, longer time to surgery was associated with number of diagnostic studies and endoscopic retrograde cholangio-pancreatography (ERCP, P = 0.01) as well with admission to medical service without adjustment for ERCP (P < 0.05). Patients undergoing both magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) scans experienced the longest waits for surgery. Patients admitted to the surgical versus medical service underwent surgery earlier (30.4 +/- 34.9 vs 82.7 +/- 55.1 h, P < 0.01), had less post-operative complications (12% vs 58%, P < 0.01), and shorter length of stay (4.3 +/- 3.4 vs 8.1 +/- 5.2 d, P < 0.01). Admission to the medical service and performance of numerous diagnostic procedures, ERCP, or MRCP combined with CT scan were associated with longer time to surgery. Expeditious performance of ERCP and MRCP and admission of medically stable patients with suspected cholecystitis to the surgical service to speed up time to surgery should be considered.

Waits for Surgery Following Hip Fracture

Almost all hip fracture patients undergo surgery to repair the fracture. Recent research suggests that timely repair is important for good outcomes following surgery. Patients who had surgical repair of a hip fracture in 2003-2004 were identified using hospitalization data collected by the Canadian Institute for Health Information. Time to surgery was calculated from day of admission to day of surgery. The associations of both patient and system characteristics with waits for surgery were considered. While the majority of patients had surgery on the day of or the day following admission, 29% waited two days or longer for surgery. Wait times were related to patients' age, hospital size, day of admission and whether patients were transferred.

A Direct Booking Hernia Service – A shorter wait and a satisfied patient

Introduction Patients requiring routine operations often have lengthy waits for outpatient appointments and surgery. Our aim was to reduce this wait by offering patients a Direct Booking Hernia Service and to assess its efficacy and its acceptability to patients. Methods Two groups of patients referred for treatment of an inguinal hernia were compared. Group 1 were those referred to a single named consultant and all those referred without specifying a consultant's name during the same period. Group 2 were those referred to any other named consultant at the same hospital during the same period. For those in Group 1, the referral letter was triaged by a single surgeon and sent directly to the Day Surgery Unit (DSU). The patient's first appointment was for nurse led pre-assessment in the DSU. At the same visit the duty DSU surgeon checked the hernia to confirm the diagnosis. If medically fit, patients were offered a date for operation within 4 weeks of their pre-assessment. If unfit for DSU, the nurses would discuss the patient with the DSU lead anaesthetist and could book them directly onto an inpatient list or refer them to the outpatient clinic. Group 2 patients followed the traditional pathway of outpatient clinic, then booking for surgery. Group 1 patients were invited to complete a patient satisfaction questionnaire following their treatment. Results There were 74 patients in Group 1 and 147 in Group 2 during the study period. In Group 1 3/74 (4.1%) did not have hernias at pre-assessment. The mean total waiting time from referral to surgery was 70 days. In Group 2 the mean wait for an out-patient appointment was 77 days, and the wait from outpatient appointment to surgery was 84 days, giving a total average waiting time of 161 days. The proportion of patients treated as day cases was 88.7% in Group 1 and 70% in Group 2. 43% of Group 1 patients responded to the questionnaire. 94% of these would recommend the service to a friend. Conclusion The Direct Booking Hernia Service provides an efficient way of treating patients requiring inguinal hernia repair that is acceptable to patients. It significantly reduces waiting times and reduces the load on outpatient appointments.

Private outlets for public limitations: the rise of commercial health insurance in Israel.

In recent years, dissatisfaction with aspects of the Israeli health care system has grown. Labor conflict and unrest, long waits for elective surgery, increases in out-of-pocket payments for health care, and declining government investment have given rise to a new phenomenon: the increasing use of private services. This has led consumers to seek financing sources for their private care and created opportunities for commercial insurers and sick funds to offer new insurance packages to meet this demand. As a result, over the last five years more than twenty commercial health policies and four mandatory supplemental policies provided by the sick funds are currently on the market. The market for these policies is small but growing, with consequences for the cost and quality of care, access, the level and composition of national expenditures, and the allocation of resources to both the public and private health systems. As the balance between private and public financing changes, so too do the trade-offs between differing objectives. Greater private pluralism and competition at the financing level have many advantages but also make it more difficult for government to manage the tradeoffs that occur. Thus, a changed emphasis in government regulation and policy-making is required.