Article

Eliciting patient views on choosing the next available surgeon to reduce waiting times for joint replacement surgery: on the need to consider individual patient preferences and information needs

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Abstract

Rationale, aims, and objectives: The objective is to understand patient views on surgeon choice when being referred for joint replacement; do they prefer referral to the next available surgeon for a shorter waiting time or do they prefer their own choice of surgeon? What factors guide this decision and what information would patients find useful when deciding? Methods: Seven focus groups were held in four Canadian cities. Participants had been either referred to or seen by an orthopaedic surgeon for hip or knee replacement surgery. The method of analysis was qualitative thematic analysis. Results: There were 50 participants, 66% female, 60% knee replacements and the average age was 66 years (SD 12). 68% were on a waiting list for surgery and 32% were undecided about surgery. Although patients varied in their views, many wanted some choice in their decision about a surgeon. If patients were in severe pain, they were more likely to accept the idea of referral to the next available surgeon. Other considerations were the recommendation of their family physician, surgeon reputation and confidence in the surgeon. Although some patients wanted access to patient outcome data and satisfaction data, others were skeptical of data and the interpretation of statistics. Conclusion: Patient views on referral to the next available surgeon are relevant to initiatives aimed at improving access to care, such as pooled surgeon waiting lists. If implemented, waiting time is not the only important factor for patients. Individual patient preferences and information needs must also be considered, given their pivotal significance in the development of person-centered approaches in clinical care.

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... The FP may make the decision after a discussion with the patient, the patient may request a particular surgeon, or may delegate the referral decision to the FP. 12 Our study had 2 main objectives: (a) to assess the determinants of a patient's request for a particular surgeon for elective TKR and THR; and (b) to determine the factors influencing the referral form option selected, that is, to either a specific surgeon versus the next available surgeon. We previously conducted focus groups of TJR patients to determine factors important to patients regarding surgeon choice and what factors patients considered if offered the choice of next available surgeon. ...
... Key findings were that patients were more accepting of going to the next available surgeon if they had severe pain, a poor quality of life, or if they had experienced long waits. 12 Other considerations were the reputation of the surgeon, hospital or clinic, confidence in the surgeon, and the FP's recommendation. Many patients wanted some choice in the decision and most patients desired surgery within a reasonable distance from their home. ...
... The items were based on our results from 7 focus groups of hip and knee patients who had been referred to or had seen an orthopedic surgeon. 12 We pretested the questionnaire items using a convenience sample of 14 post-TJR patients and colleagues. Respondents completed the questionnaire and also reviewed its clarity, wording, and interpretation. ...
Article
Background: Although the option of next available surgeon can be found on surgeon referral forms for total joint replacement surgery, its selection varies across surgical practices. Objectives: Objectives are to assess the determinants of (a) a patient's request for a particular surgeon; and (b) the actual referral to a specific versus the next available surgeon. Methods: Questionnaires were mailed to 306 consecutive patients referred to orthopedic surgeons. We assessed quality of life (Oxford Hip and Knee scores, Short Form-12, EuroQol 5D, Pain Visual Analogue Scale), referral experience, and the importance of surgeon choice, surgeon reputation, and wait time. We used logistic regression to build models for the 2 objectives. Results: We obtained 176 respondents (response rate, 58%), 60% female, 65% knee patients, mean age of 65 years, with no significant differences between responders versus nonresponders. Forty-three percent requested a particular surgeon. Seventy-one percent were referred to a specific surgeon. Patients who rated surgeon choice as very/extremely important [adjusted odds ratio (OR), 6.54; 95% confidence interval (CI), 2.57-16.64] and with household incomes of $90,000+ versus <$30,000 (OR, 5.74; 95% CI, 1.56-21.03) were more likely to request a particular surgeon. Hip patients (OR, 3.03; 95% CI, 1.18-7.78), better Physical Component Summary-12 (OR, 1.29; 95% CI, 1.02-1.63), and patients who rated surgeon choice as very/extremely important (OR, 3.88; 95% CI, 1.56-9.70) were more likely to be referred to a specific surgeon. Conclusions: Most patients want some choice in the referral decision. Providing sufficient information is important, so that patients are aware of their choices and can make an informed choice. Some patients prefer a particular surgeon despite longer wait times.
... Recent related studies in the literature have shown that some patients (typically older) awaiting surgery may prefer to see a surgeon of their choice (over the next-available), citing trust, surgeon reputation and a willingness to wait longer. [40][41][42][43] Future research Additional studies are needed which explore the acceptability of all related stakeholders that would be affected by SEMs, including family members, GPs, surgeons, office assistants and decision-makers. Their viewpoints are of tremendous importance given the diverse roles they play on the continuum of care for elective surgical services. ...
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Background Single-entry models (SEMs) for the management of patients awaiting elective surgical services are designed to increase access and flow through the system of care. We assessed scope of use and influence of SEMs on access (waiting times/throughput) and patient-centredness (patient/provider acceptability). Methods Systematic review of articles published in 6 relevant electronic databases included studies from database inception to July 2016. Included studies needed to (1) report on the nature of the SEM; (2) specify elective service and (3) address at least 1 of 3 research questions related to (1) scope of use of SEMs; (2) influence on timeliness and access; (3) patient-centredness and acceptability. Article quality was assessed using a modified Downs and Black checklist. Results 11 studies from Canada, Australia and the UK were included with mostly weak observational design—2 simulations, 5 before–after, 2 descriptive and 2 cross-sectional studies. 9 studies showed a decrease in patient waiting times; 6 showed that more patients were meeting benchmark waiting times; and 5 demonstrated that waiting lists decreased using an SEM as compared with controls. Patient acceptability was examined in 6 studies, with high levels of satisfaction reported. Acceptability among general practitioners/surgeons was mixed, as reported in 1 study. Research varied widely in design, scope, reported outcomes and overall quality. Conclusions This is the first review to assess the influence of SEMs on access to elective surgery for adults. This review demonstrates a potential ability for SEMs to improve timeliness and patient-centredness of elective services; however, the small number of low-quality studies available does not support firm conclusions about the effectiveness of SEMs to improve access. Further evaluation with higher quality designs and rigour is required.
Article
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Objectives We 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 quality: accessibility, acceptability, appropriateness, effectiveness, safety. Design Preimplementation/postimplementation cross-sectional design comparing historical (n=2282) and prospective (n=2397) cohorts. Setting Regional, provincial health authority. Participants Patients awaiting total joint replacement of the hip or knee. Interventions The WCIS is a single-entry model (SEM) to improve access to total hip replacement (THR) or total knee replacement (TKR) surgery, implemented to minimise variation in total waiting time (TW) across orthopaedic surgeons and increase the proportion of surgeries within 26 weeks (benchmark). Impact of SEMs on quality of care is poorly understood. Primary and secondary outcome measures Primary outcomes related to ‘accessibility’: waiting time variation across surgeons, waiting times (Waiting Time 2 (WT2)=decision to treat until surgery and TW=total waiting time) and surgeries within benchmark. Analysis included descriptive statistics, group comparisons and clustered regression. Results Variability in TW among surgeons was reduced by 3.7 (hip) and 4.3 (knee) weeks. Mean waiting was reduced for TKR (WT2/TW); TKR within benchmark increased by 5.9%. Accessibility and safety were the only quality dimensions that changed (post-WCIS THR and TKR). Shorter WT2 was associated with post-WCIS (knee), worse Oxford score (hip and knee) and having medical comorbidities (hip). Meeting benchmark was associated with post-WCIS (knee), lower Body Mass Index (BMI) (hip) and worse Oxford score (hip and knee). Conclusions The WCIS reduced variability across surgeon waiting times, with modest reductions in overall waits for surgery. There was improvement in some, but not all, dimensions of quality.
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