Developing a universal tool for the prioritization of patients waiting for elective surgery

Abstract

The objective was to elaborate a priority scoring system for patients on waiting lists for elective surgery to be implemented in the Catalan public health system. This tool should ideally be universal (for all patients and across the entire region) with common criteria and weights (for all surgical procedures), simple and user-friendly.

A tool based on a point-count linear scale ranging from 0 (lowest priority) to 100 (highest priority) was developed. Patients are scored in three major dimensions: clinical and functional impairment, expected benefit, and social role, which include 8 criteria (with their weights): disease severity (23%), pain (or other main symptoms) (14%), rate of disease progression (15%), difficulty in doing activities of daily life (14%), probability and degree of improvement (12%), being dependent with no caregiver (5%), limitation to care for one's dependents (if that be the case) (8%), and limitations in the ability to work, study or seek for employment (9%). As in previous studies developed in Canada, New Zealand and Catalonia, the tool obtained is mainly based on severity and need. The success of this tool depends very much on implementation mechanisms. Furthermore, prior to implementation, a definition of specificities in the selected criteria for the most frequent surgical procedures is advised.

Introduction

In countries with publicly funded health-care systems, if waiting lists have been cyclically the subject of political debate, this is ever more so now in the context of recent implemented budget cuts in European countries. Furthermore, there is increasing pressure for the implementation of an equitable and patient needs-based, rather than process-based, system to rationing surgery [1], [2]. For this reason, the establishment and implementation of criteria for setting a patient's priority has come under increasing scrutiny [3]. Countries profoundly affected by recent austerity measures like Spain are reluctant to publish refined figures, comparable across years or regions. One reason for this is the variety of possible definitions to establish when a patient starts waiting, what the reason is and for how long. This explains why in 2013 the national official data on waiting lists for Spain, and Catalonia in particular, do not allow conclusive lessons to be learned regarding the impact that the austerity measures are having on waiting times for patients [4].

An argument in favour of the introduction of priority scoring systems is transparency, with the inclusion of explicit and not arbitrary prioritization criteria [5], which are probably already being used routinely and implicitly but in a non traceable way. They also carry some advantages for managers (i.e. characterization of waiting lists, characterization of people waiting for services, etc.), which could help inform the decision making and implementation of new management measures [6]. In addition, the prioritization of patients on a waiting list also aims to diminish the burden of waiting lists [7].

The development of prioritization instruments has been the strategy followed by some countries like New Zealand, Canada and the United Kingdom among others to manage waiting lists according to patient's needs and expected benefit from surgery [8]. It involves the use of priority scoring tools which are means to generating a score with which to prioritize the access of patients to elective surgery services [8]. The development of these instruments is a lengthy and costly process, and in general, has been focused on specific diseases. Although evidence is not conclusive, one might expect that establishing common criteria for all types of surgical procedures might to simplify the implementation process and allow for a comparable tool to be used across different procedures [9].

In Catalonia (Spain), the public healthcare insurance (CatSalut) is willing to change the current model of organizing waiting lists for elective surgery. The new model would be based on the need to change from a system based on procedures (prioritization of procedures by fixing waiting-time guarantees) to a universal system based on a patient's needs and expected benefit from surgery. Although designed for implementation in Catalonia, the approach based on patients’ needs and benefit (rather than a process-based approach) should aim to be valid for other populations. In fact, the tool should have common criteria and weights for all patients and surgical interventions; and based on a point-count linear scale considering both clinical and functional, as well as social criteria.

The aim of this study was to develop a universal priority scoring system, homogeneous throughout the country and for all patients, and with standard criteria for all conditions. In particular, we wanted to identify and develop a number of common criteria and their weights for priority setting of patients on waiting lists for elective surgical procedures. This prioritization tool (framework) will be the starting point to develop tools suitable for prioritizing patients for specific conditions.