key: cord-0290501-vumm06ze
authors: Rathnayake, D.; Clarke, M.; Jayasinghe, V.
title: Patient prioritisation methods to shorten waiting times for elective surgery: a systematic review of how to improve access to surgery
date: 2021-02-21
journal: nan
DOI: 10.1101/2021.02.18.21252033
sha: 91a9db5892a872ccb31d427a6b8243a41421abae
doc_id: 290501
cord_uid: vumm06ze

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 a 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. Keywords: Patient prioritisation, elective surgery, waiting time, systematic review

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 reordering the waiting list for a particular surgical specialty. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 21, 2021 

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.

Waiting times are a key performance indicator for many healthcare systems and waiting-time targets are used to encourage improved performance in healthcare institutions to deliver highquality care without unnecessary delay (1). The COVID-19 pandemic has already added considerably to this challenge, leading to a considerable increase in the pressure on healthcare institutions to clear patients in clinics. The healthcare system slowdown caused by the pandemic and its associated measures has had a substantial impact on elective services (2) and efficient allocation of elective surgical resources are more critical than ever in the business as unusual (BAUU) future for healthcare systems and institutions (3) . There is also a need for strategies implemented during the pandemic to be continually integrated into hospital practices, to minimise the risk of transmission of the coronavirus (4) .

Waiting lists are considered as a non-price rationing mechanism for coping with excess demand. Long waiting times are associated with many adverse effects, including a higher risk of death and serious complications for patients, especially adults (5) (6) (7) (8) (9) (10) . Consequently, waiting times for elective surgeries are a major policy concern in many countries, especially for health systems operated with public funds (11) . Despite increased funding in recent years, the demand for many elective surgeries exerts a substantial challenge, which was growing even before the COVID-19 pandemic (12) . The negative impact of patient waiting time on cost-effectiveness in economic evaluations has also found to be non-reversible (13) (14) (15) and there is a need for economic evaluations, adapted to outbreak situations (16) , to estimate the specific impact of COVID-19 pandemic on the pre-existing crisis of longer waiting times. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 21, 2021. ; https://doi.org/10.1101/2021.02.18.21252033 doi: medRxiv preprint A large amount of literature is available on a large array of methods to reduce patient waiting times for elective surgeries. The research focus has shifted recently to individual strategies, rather than system-wide approaches. One of these strategies is to prioritise patients, such that the waiting list is re-ordered. Although prioritisation does not always reduce total waiting time for all patients, it allows those patients in the greatest need to be treated first.

Prioritisation processes are used in many countries to order the queue of patients for highdemand surgeries, and many research studies have demonstrated promising results for various patient prioritisation methods, but there are few systematic reviews of the effects of these methods. As an example, a systematic review done in 2003 on patient prioritisation for elective surgery sought to determine the basis of ethical approaches used in different prioritisation tools (17) , and other systematic reviews have analysed different approaches to reduce waiting times for elective surgery (18) (19) (20) . To bridge the evidence gap in the current literature, this systematic review seeks to identify opportunities to shorten waiting times for elective surgery with a particular focus on patient prioritisation methods. It seeks to answer the following "What are the effective patient prioritisation methods to reduce waiting times for elective surgeries and how consistent were those results to different elective surgical specialties, institutions, and health systems?"

This review is one of the sub-reviews in a major systematic review conducted with a broader search to support a holistic approach to finding solutions for long waiting times for elective surgery. It assesses patient prioritisation as one strategy among a much wider scope of approaches. The full, portfolio review was registered in PROSPERO (CRD42019158455) and its PRISMA flow diagram is attached (Supplementary online file 1). The broad scope allows . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint for the inclusion of all methods, strategies, and policies to reduce waiting times for elective surgery. For this sub-review, studies on patient prioritisation methods were deemed eligible, and it was conducted and reported according to the PRISMA statement and checklist (Supplementary online file 2). Given that healthcare system interventions are often tested in quasi-experimental studies or observational studies, rather than experimental studies (such as randomised trials), a range of study designs were eligible for this review. With this in mind and because the validity of the results of any systematic review of health system interventions is dependent on the use of relevant evidence and synthesis methods (21), we used design-specific tools to evaluate the risks of bias associated (22) , as discussed below.

Data sources for the portfolio review:

We searched PubMed, EMBASE, SCOPUS, Web of Science, and the Cochrane Library using combinations of search terms. After pilot searches, we finalised a detailed search strategy which consisted of three sets of search terms without language restrictions. The searches were run from 14 December 2019 to 7 January 2020, for articles published from 1 January 2014 to December 2019. The search strategy used for PubMed is presented in Supplementary online file 3.

Criteria for considering studies for the review:

We included studies that investigated interventions and strategies intended to reduce waiting time for elective surgery. We included original research published in journal papers, reports, editorials, and literature reviews from the health sector, government, and related sectors. We included experimental, quasi-experimental, and observational studies, as well as systematic reviews published during 2014-2019. Qualitative and quantitative data were considered for data synthesis; but simulation and modelling studies were excluded, because they might not be a reliable guide to the effects in real-world scenarios. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint waiting for all types of major elective surgery were eligible, except for those of patients waiting for cancer or cancer-related surgeries. The surgeries require penetration of a body cavity are considered as major surgeries and all surgeries of abdomen, chest or cranium are considered major surgeries. Minor surgeries are generally superficial and do not require penetration of a body cavities (23) . Although most eye surgeries are minor surgeries, studies on eye surgery lists were included as an exception, because these have some of the longest surgery waiting lists in many countries (24) . For this review, where a study was based in a clinic or outpatient department, we required that the investigation was targeted on the prioritisation of patients registered for elective surgery, rather than patients waiting for other procedures.

Article selection and data extraction:

DR and VJ to select relevant articles checked the title and the abstract of retrieved citations.

Articles that were deemed potentially eligible based on their title or abstract were retrieved in full and assessed for eligibility and relevance. Each potentially eligible article was discussed with the third reviewer (MC) and agreement was reached on inclusion or exclusion.

The portfolio review includes a wider scope and data synthesis for this review was carried out as a single subgroup analysis of that wide series of systematic reviews. Meta-analyses were not applicable for this review because of the heterogeneity in study designs and variability of the approaches to how the outcome of interest was measured. Instead, we planned a meta-synthesis with narrative analysis. Given the types of study that we identified, we used the ROBINS-I tool (25) for quality evaluation in non-randomized intervention studies and the CASP tool (Critical is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint Appraisal of Skill Programme) for observational studies (26) . We would have used the Cochrane Risk of Bias tool for randomized trials, but none were identified for this review. We used common criteria to report the overall quality of evidence in observational studies.

The article screening process is shown as a PRISMA flowchart (Figure 1 ). The electronic search for the full review yielded 7543 records from the five bibliographic databases. This reduced to 5346 after deduplication in EndNote citation management software. During the title and abstract screening process, 362 potentially relevant citations were selected, and this was reduced to 196 articles after full article screening for the extended scope of the full, portfolio review. Of these, 105 simulation and modelling studies were rejected at this stage. After grouping the citations to different strategies for the same intended outcome of reducing waiting times, 17 articles were judged eligible for this sub-review because their major emphasis was on methods for prioritising patients to reduce waiting time for elective surgery.

Our primary outcome variable is waiting time, which was defined as the period between a surgeon placing a patient on the waiting list for a particular elective surgery and the day that the surgery is performed. In total, we included 17 studies that were published between 2014 and 2019: four quasi-experimental studies, 11 observational studies and two systematic reviews. A summary is presented in Table 1 . Of the 15 original studies (excluding the two systematic reviews), ten described prioritisation as a health system-wide approach, and five tested patient prioritisation as an institutional measure, investigating the association of waiting time with an explicit prioritisation guideline.

. CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint Systematic review 2 (12%)

Institution 5 (33%)

Health system 10 (67%) *Two systematic reviews excluded . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 21, 2021.

Elective surgery 4 (23%)

Orthopaedic surgery 5 (29%)

Eye surgery 2 (12%)

Bariatric surgery 2 (12%)

General surgery 1 (6%)

Plastic surgery 1 (6%)

Summary of included studies:

The characteristics of the 17 included studies are summarised below and further details are given in Table 2 .

Laberge (27) investigated the effects of delays and waiting times for total joint replacement (TJR) surgery using observational study methods. The study was conducted in a university- is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint Gangstoe (33) reported a cross-sectional study of the variation in priority status and waiting times across different medical disciplines for elective patients admitted to specialized services in Norway, in 2010. Considerable variation was found across medical specialties, with causes for variation often interpreted as differences in clinical judgment and capacity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 21, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 21, 2021. ; https://doi.org/10.1101/2021.02.18.21252033 doi: medRxiv preprint interventions based on prioritisation strategies, and quality management improvements of the surgical pathways and improvements in the planning of the surgical schedule.

The quality of the individual studies that we included in this review was measured using two tools. In addition to the four intervention studies, we evaluated three of the other studies with ROBINS-I considering the longitudinal assessment of their outcome variable (29, 30, 35) . The relevant CASP reading tool was used to evaluate the other ten studies.

We judged five studies to have an overall moderate quality ( (29, 30, 35, 37, 40) and two studies to have a serious risk of bias in their methodology (32, 39) . Details of ROBINS-I evaluation for each domain is shown in Figure 2 and Figure 3 .

All seven of these studies had inclusion and exclusion criteria for study participants, but none had used randomisation to allocate participants to the assessed prioritisation processes. We is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 21, 2021. ; https://doi.org/10.1101/2021.02.18.21252033 doi: medRxiv preprint However, one study had a serious risk of selection bias of reported results because of the limitation of using admission data only from those patients who had completed the waiting period. In this study, the number of patients who had not attended the admission was not reported (39) . Outcome variables included in many studies were as intended, namely a measurement of the time spent on the waiting list, which was unbiased. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint 

CASP tools: The main outcome variable of interest for this review is a time-to-event measurement, which required the follow up of a cohort of patients and various time measurements in these study participants. We applied the CASP checklist for cohort studies to six included studies (10, 27, 28, 33, 36, 38) and the CASP checklist for Qualitative studies to two studies (31, 34) . The two systematic reviews were assessed using the CASP checklist for systematic reviews.

We assessed most studies to be of moderate to low risk of bias. The evidence from most studies is sufficient to support their results (10, 27, 31, 33, 34, 36, 41, 42) . However, one study demonstrated poor study methodology because confounding factors were not considered when recruiting study participants or in the data analysis (43) . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint 

Seventeen research studies were eligible for this narrative synthesis. Meta-analyses were not possible or appropriate because of the substantial heterogeneity across the studies. Prioritisation strategies for waiting lists incorporate equity criteria (44) and, so, as a first step in our narrative synthesis, we focused on the levels of implementation of the prioritisation systems in each study. Many prioritisation scores were recommended to be used for individual disciplines and there were two apparent approaches. First, is the generic approach that could be used as a universal prioritisation criterion for all types of elective surgeries (10, 39, 45) . Secondly, the prioritisation criteria were specifically based on measures related to the particular clinical status and recommended for managing the queue for a particular surgery or surgical specialty: orthopaedic surgery (27, 30, (35) (36) (37) , general surgery (29), neurosurgery (33, 34) , bariatric surgery (38, 42) , eye surgery (32) and plastic surgery (31) .

The goals of a prioritisation methodology should be achieved with scientifically valid prioritisation tools with a transparent mechanism (46) . The presented studies have variable risks of bias at varying stages, due to deficiencies in their methods ( Table 2) and their results are mixed. The total joint replacement surgery patients that were prioritised by the MAPT (Multi attribute Prioritisation Tool) had improved clinical outcomes with a significantly shorter waiting time (30) . Similarly, prioritising patients for cataract surgery using the NIKE (National Indications model for Cataract Extraction) tool reduced waiting times for surgery for those with the greatest need (40) . One included study reported on variations of prioritisation among different medical disciplines, which was interpreted mostly as the result of the differences in clinical judgment in various clinical scenarios (33) . None of the studies investigated vertical equity approaches of prioritising methods to re-order the waiting list for different elective surgeries using different weights across disciplines, besides vertical equity is often justified by clinical urgency (47) . However, standardised universal prioritisation tools were recommended is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 21, 2021. ; https://doi.org/10.1101/2021.02.18.21252033 doi: medRxiv preprint in one study to maintain vertical equity, which would re-order the queue for different specialties in the theatre time allocated to different elective surgery lists (10) .

The adverse health outcomes due to long waiting lists for elective surgery are a general policy issue in many countries (48) (49) (50) . Many of the prioritisation-related interventions that were tested in included studies, were aimed to implement in regional levels or as health system-wide approaches (10, 27, 31, 33, (36) (37) (38) (39) (40) 42 ) while a smaller number of studies focused on single surgery units or individual hospitals (29, 30, 32, 34, 35) .

Prioritisation tools based on objective measures of disease severity scales are known as Clinical Priority Assessment Criteria (CPAC) and these have been commonly used in public hospitals (51) . Irrespective of whether an explicit CPAC based on clinical parameters was available, it was reported that the order of patients in the surgery list was nearly the same, since clinicians have naturally used their own best judgment to order the queue for the surgery, based on clinical urgency (37) . This reflects that clinical parameters alone will not demonstrate the pure urgency and suffering of the respective patient's condition.

Previous research has identified many potential structural barriers to equitable access to elective surgical care (51) and the importance of prioritisation to the fair allocation for services.

Longer waiting times have shown higher detrimental effects to people in lower socio-economic categories (52) . Consideration of such equity principles, moral considerations and socioeconomic parameters of the patients were suggested as ways to determine the genuine priority access for elective surgery in some included studies (10, 35) . The importance of considering moral concerns of patients for prioritisation has also been highlighted for non-life-threatening conditions, such as elective plastic surgeries (31) . The added advantage of considering the patients' perspectives minimises discrimination and leads to patient-centred operating systems. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted February 21, 2021. ; https://doi.org/10.1101/2021.02.18.21252033 doi: medRxiv preprint Some studies included in this review showed that multi-attributes in the prioritisation tools tested for the selected surgeries had a strong association with shorter waiting times along with better post-surgical treatment outcomes (17, 30) .

This review also explored different practical approaches to obtain objective measurements for priority scoring. To avoid the limitations of subjective assessments, some studies have recommended the combination of clinician judgment with investigations, reports and details of patient-reported concerns to develop a fair prioritisation tool (10, 31) . Instead of the surgeon's assessment of the clinical or anatomical features of the patient, patient-reported perceived health concerns (40) might indicate a greater need for surgery to a particular patient than others in the queue.

Manipulations and resistance for implementing priority-scoring systems by clinicians have been reported in some studies (51, 53) . Similarly, one included study reported that the doctors had not complied with a simple clinical priority guideline which was implemented at the procedural level (39) . This indicates the need to convince clinicians on the relative importance of prioritisation and the need to include non-medical factors when determining access to rationed services.

One of the systematic reviews that we included assessed the factors of prioritisation of elective surgical patients in a single surgeon's waiting list, where the same surgery is managed by many surgeons with multiple surgical lists (41) . Unacceptable variability among waiting times in the same specialty in different surgeons or centres and variability in waiting times among different specialties need to be balanced to achieve horizontal and vertical equity for access to health care (44) . Adapting prioritisation principles at earlier stages, when the patients were referred to surgical clinics has also been shown to be effective in providing timely services (54) . This information might help healthcare managers and policy makers to enhance the local applicability of the implemented prioritisation tools and methods. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint given prioritisation parameters to individual surgeries. Instead, we aimed to provide a holistic approach for prioritisation policies, which could be customised to adapt to any healthcare system. Finally, we have not been able to use the quantitative results of the studies to present meta-analyses of the effects of the interventions or to determine if publication bias has impacted on our conclusions, because of the heterogeneity among the studies.

Considering all the quality appraised evidence in the 17 included studies, we have found that this suggests that strategies that support the prioritisation methods suggest can achieve faster access for the patients on waiting lists who are in most need of the surgical care. Having standardised specific prioritisation tools for each specialty is more likely to be effective for horizontal equity by re-ordering the queue of patients waiting for a particular surgery list, but is unlikely to impact on vertical equity across different types of surgery or condition. In addition to clinical assessments, incorporating socio-economic parameters and patients' moral considerations into prioritisation scoring systems is more effective and more likely to avoid system-associated discrimination in certain surgical specialties. It is challenging to formulate a transparent and consistent national prioritisation system for elective surgeries, but an explicit prioritisation tool with a transparent and objective scoring system based on clear evidencebased criteria might reduce the waiting time for elective surgery.

In summary, this review has listed some factors in a framework (Figure 4 ) that would address the most important questions asked by healthcare managers and policy makers when seeking a fair prioritisation system for elective surgeries to overcome limitations with local variations.

This may be especially important given the impact of the COVID-19 pandemic on elective surgery waiting lists in many countries, and the depletion of resources for routine health care. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint However, more research is needed, ideally in the form of randomised trials to quantify the effects of these interventions, as well as economic evaluations leading more precise evidenceinformed decision-making.

. CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint To discuss moral principles that can be used as a guide for health professionals to revise and create policies for plastic surgery patients presenting with nonlife-threatening conditions.

Discuss in detail on patientcantered operating system and patient's informed preferences which might be implemented in the process of prioritizing health.

A specific anatomical feature is not always an indicator of patient's well-being, good policies should identify the worst-off, and those who can mostly benefit from surgery such as a patient-centred operating system, and patient's informed preferences. Revised operational concepts and new facilities together with a 15% increase in work contribution led to a 46% increase in overall productivity, improved access to care and the clearance of delayed services.

Dealing with waiting times in health systems -An international comparative overview

Health system performance and health system preparedness for the post-pandemic impact of COVID-19: A review

Surgical wait list management in Canada during a pandemic: many challenges ahead

Approaching Surgical Triage During the COVID-19 Pandemic

Wait Time for Hip Fracture Surgery and Mortality

Do maximum waiting times guarantees change clinical priorities for elective treatment? Evidence from Scotland

Impact of Surgical Waitlist on Quality of Life

The cancelling of elective surgical operations causes emotional trauma and a lack of confidence: study from a urological department

How often does the operating list follow the planned order? An analysis of elective maxillofacial operating lists. The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland

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An introduction to economic studies, health emergencies, and COVID-19

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

Inclusion of quasiexperimental studies in systematic reviews of health systems research

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The cataract surgery access debate: why variation may be a good thing

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Critical Appraisal Skills Programme UK2018

Clinical pathway efficiency for elective joint replacement surgeries: a case study

Obesity Surgery Score (OSS) for Prioritization in the Bariatric Surgery Waiting List: a Need of Public Health Systems and a Literature Review

General Surgery Prioritization Tool: a pilot study

Evaluation of the Multi-Attribute Prioritisation Tool for Total Joint Replacement

Prioritization for Plastic Surgery Procedures Aimed to Improve Quality of Life: Moral Considerations

Right services to right patients at right time in right setting in Tays Eye Centre

Norwegian priority setting in practice -An analysis of waiting time patterns across medical disciplines

Patients' views on priority setting in neurosurgery: A qualitative study

The Impact on Life questionnaire: validation for elective surgery prioritisation in New Zealand prioritisation criteria in orthopaedic surgery

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Impact of a priority system on patients in waiting lists for knee arthroplasty

Prioritization and willingness to pay for bariatric surgery: the patient perspective

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Impact of a National system for waitlist prioritization: The experience with NIKE and cataract surgery in Sweden

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Obesity Surgery Score (OSS) for Prioritization in the Bariatric Surgery Waiting List: a Need of Public Health Systems and a Literature Review

Cholecystectomy audit: Waiting time, readmissions and complications

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The effectiveness of different patient referral methods on waiting times for adults needing elective surgery -Systematic review

The study concludes that although the fulfilment of the priority system is significant, its impact on the order of operations performed is not, which does not seem to differ from a FIFO system.

Gill (38)