Open Access Open Access  Restricted Access Subscription or Fee Access

Equity of access and variation in general surgeons’ clinical judgements of patient priority

Patrick Graham, Greg Martin, John Fraser John Fraser, Jacqueline Cumming, Helen Williams, Ann Davidson, Bryan Parry, Justin Roake, Andre van Rij

Abstract


Rationale, aims and objectives: In New Zealand, access to publicly funded elective surgery is rationed by explicit prioritisation of patients, with those scoring above a threshold offered surgery and others referred back to their general practitioner for on-going management. The reliability and validity of the priority scoring systems which underpin this approach to managing the demand for elective surgery have been questioned on many counts, not least their implications for a properly person-centered medicine. The objective of this research was to examine variability in surgeon priority scoring within general surgery.

Method: Using an observational cross-sectional study design, 911 patients were assessed by one of 48 general surgeons who rated priority for surgery using a 100mm visual analog scale. Patients completed a questionnaire recording disease severity indicators. A hierarchical Bayesian model was used to estimate between and within surgeon variation in priority scoring, adjusting for patient-reported disease severity.

Results: Across 3 study centres and 3conditions, estimated standard deviations ranged from 2.0 (95% CI 0.1-6.5) to 11.6 (7.2-20.3) and from 6.1 (4.7-8.0) to 15.6 (12.8 -19.9) for between and within surgeon variability, respectively. In the majority of comparisons, within-surgeon variation exceeded between-surgeon variation. Using the hierarchical model we estimated the probability that two specialist surgeons scoring patients with identical patient-reported severity indicators would agree to within 10 points. These estimates ranged from 0.31 (95% CI 0.24-0.37) to 0.72 (0.57-0.80).

Conclusion: There was, in general, marked variability in surgeons’ scoring of patient priority.  Variation in scoring of patient priority must affect equity of access to surgery and therefore have direct implications for person-centered medicine.. Strategies to reduce this variation are warranted.


Keywords


Bayesian modelling, clinical priority, doctor behaviour, elective surgery, health services research, healthcare access, healthcare equity, person-centered medicine

Full Text:

PDF

References


Fraser, G., Alley, P. & Morris, R. (1993). Waiting Lists and Waiting Times; Their Nature and Management. Wellington, New Zealand.

Gauld, R. & Derrett, S. (2000). Solving the surgical waiting list. International Journal of Health Planning and Management 15, 259-272.

Chen, T.Y.T., Landmann, M.G., Potter, J.C. & van Rij, A.M. (2006). Questionnaire to aid priority and outcomes assessment in gallstone disease. ANZ Journal of Surgery 76 (7) 569-574.

MacCormick, A.D. & Parry, B.R. (2006). Judgment Analysis of Surgeons' Prioritization of Patients for Elective General Surgery. Medical Decision Making 26 (3) 255-264.

Roake, J., Doughty, C., Hider, P., Fraser, J., Kirk, R., MacCormick, A., et al. (2003). Reliability of surgical priority tools in vascular surgery. ANZ Journal of Surgery 73 (Supplement) A121.

Hadorn, D.C. & Holmes, A.C. (1997). The New Zealand priority criteria project. Part 1: Overview. British Medical Journal 314 131-134.

Hadorn, D.C. & Holmes, A.C. (1997). The New Zealand priority criteria project. Part 2: Coronary artery bypass graft surgery. British Medical Journal 314 135-138.

Dennett, E. & Parry, B. (1998). Generic surgical priority criteria scoring system: The clinical reality. New Zealand Medical Journal 111 163-166.

MacCormick, A., MacMillan, A. & Parry, B. (2004). Identification of criteria for the prioritisation of patients for elective general surgery. Journal of Health Services Research & Policy 9 (1) 28-33.

MacCormick, A., Plank, L., Robinson, E. & Parry, B. (2002). Prioritizing patients for elective surgery: clinical judgement summarized by a linear analogue scale. ANZ Journal of Surgery 72 613-617.

Dennett, E., Kipping, R., Parry, B. & Windsor, J. (1998). Priority access criteria for elective cholecystectomy: a comparison of three scoring methods. New Zealand Medical Journal 111 231-233.

BUGS: Bayesian inference using Gibbs Sampling (program). (2002). Cambridge, England: MRC Biostatistics Unit.

Gelman, A. & Hill, J. (2007). Data Analysis Using Regression and Multilevel/Hierarchical Models, pp. 428-434. New York: Cambridge University Press.

Chilvers, R. (2002). Evidence into practice - an application of psychological models of change in evidence-based implementation. British Journal of Psychiatry 181 99-101.

McKee, M. & Clarke, A. (1995). Guidelines, enthusiasms, uncertainty, and limits to purchasing. British Medical Journal 310 101-104.

Moulding, N., Silagy, C. & Weller, D. (1999). A framework for effective management of change in clinical practice: dissemination and implementation of clinical practice guidelines. Quality Health Care 8 (3) 177-183.

Sicotte, C. (1996). The diluting effect of medical work groups on feedback efficacy in changing physician’s practice. Journal of Behavioural Medicine 19 (4) 367-382.

Rashidian, A., Eccles, M.P. & Russell, I. (2008). Falling on stony ground? A qualitative study of implementation of clinical guidelines' prescribing recommendations in primary care. Health Policy 85 (2) 148-161.

Mid-Hampshire Health Authority. (1999). Managing Orthopaedic/Ophthalmic Demand for Equity in Localities: The MODEL Project. Hampshire, England.

Noseworthy, T.W., McGurran, J.J., Hadorn, D.C. & Steering Committee of the Western Canada Waiting List Project. (2003). Waiting for scheduled services in Canada: Development of priority-setting scoring systems. Journal of Evaluation in Clinical Practice 9 (1) 23-31.

Siciliani, L. (2005). Tackling excessive waiting times for elective surgery: A comparative analysis of policies in 12 OECD countries. Health Policy 72 201-215.

Street, A. & Duckett, S. Are Waiting lists inevitable. Health Policy 36, 1-15.

Valente, R., Testi, A., Tanfani, E., Fato, M., Porro, I., Santo, M., Santori, G., Torre, G. & Ansaldo, G. (2009). A model to prioritize access to elective surgery on the basis of clinical urgency and waiting time. BMC Health Services Research 9, 1.

Russell, C., Roberts, M., Williamson, T.G., Jolly, S.E. & McNeill, J. (2003). Clinical categorization for elective surgery in Victoria. ANZ Journal of Surgery 73 (10) 839-842.




DOI: http://dx.doi.org/10.5750/ijpcm.v2i4.298

Refbacks

  • There are currently no refbacks.