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Western Canada Waiting List Investigators

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Western Canada Waiting List Investigators Knowledge Transfer & Research Workshop Ch teau Laurier Hotel, Ottawa March 23, 2011 – PowerPoint PPT presentation

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Title: Western Canada Waiting List Investigators


1
Western Canada Waiting List Investigators
  • Knowledge Transfer Research Workshop
  • Château Laurier Hotel, Ottawa
  • March 23, 2011

2
KT Research Workshop
  • Objective
  • To disseminate and discuss recent and
    ongoing findings from the research of WCWL
    Investigators

3
WCWL Investigators funding support
4
WCWL Investigators Team for Project 1
On Behalf Of Claudia Sanmartin Barb Spady Cy
Frank Michael Carter Gillian Hawker Deborah
Marshall Carolyn De Coster Eric Bohm Mike
Dunbar Sherry Weaver Diane Lorenzetti
Marie-Pascale Pomey Peter Faris Tom Noseworthy
5
WCWL Mission
improve the fairness of the system such that
access to appropriate and effective health care
is timely and prioritized on the basis of need
and potential to benefit.
6
A Menu of Waiting Time Management Strategies
  • Process redesign efficiency optimization
  • Single-entry models
  • Priority-setting tools
  • Waiting time targets care guarantees
  • Patient choice systems
  • Simulation, scheduling and operations research
  • Appropriateness
  • Health promotion disease/injury prevention
  • Past Present Research by WCWL Investigators

7
Questions to be Addressed in Managing Waiting
Times for Scheduled Services
  • Questions to be addressed
  • WCWL research program (Funded by AI-HS CIHR)
  • Should this patient be placed in the queue?
  • What is the correct order for the queue?
  • How long should this patient wait?
  • Can we offer a certain waiting time?
  • What can make the waiting time experience better?
  • Appropriateness
  • Priority-setting
  • Maximum acceptable waiting times
  • Operations research and scheduling
  • Patient expectations

8
Priority-setting Priority Criteria scores (PCS)
  • OBJECTIVE Improve Fairness
  • To correctly order the queue
  • To develop valid, reliable, practical and
    clinically transparent measures of patients
    priority for scheduled services

9
WCWL Priority Criteria Scores (PCS)
  • Hip Knee Replacement (10 revision)
  • General Surgery (all case types, including
    cancer)
  • Cataract Removal (good bad eyes)
  • Childrens Mental Health (all case types)
  • MRI (all case types)

10
Priority Score Methodology
  • Model clinicians judgment of urgency
  • acceptable to, and endorsed by, clinicians
  • Deliberative panel of physicians
  • Panel informed by literature synthesis
  • Clinical scenarios used for formulation
  • Criteria clinical, social/role delta benefit
  • Point-count, additive scoring systems
  • (range 0 (least) - 100 (most))
  • Used to order the queue

11
WCWL Priority Criteria Score Hip Knee
Criteria ( Weights)
  • Pain on motion (13)
  • Pain at rest (11)
  • Ability to walk without pain (7)
  • Functional (ADL) limitations (19)
  • Threat to role, independence (20)
  • Abnormal orthopedic findings (10)
  • Potential for progression of disease (20)

12
WCWL Priority Referral Score Hip Knee
(Criteria weights)
  • Pain on motion (17)
  • Pain at rest (13)
  • Ability to walk without pain (14)
  • Functional (ADL) limitations (10)
  • Threat to role, independence (9)
  • Abnormal orthopedic findings (11)
  • Walking Aids (14)
  • Level of Medication (12)

13
WCWL Hip Knee PCS
Performance Characteristics
  • r2 0.676 (priority criteria account for
    two-thirds of the statistical variance in
    clinicians global urgency rating (VAS)
  • r2 0.706 (if revision arthroplasty eliminated)
  • Inter-rater/Intra-rater reliability (6
    video-taped patients)

14
Inter- and Intra-rater Reliability of Hip and
Knee PCS
PCS Criteria Inter-rater (June 2000) N19 Inter-rater (Dec 2000) N14 Inter-rater (Jan 2001) N11 Intra-rater (Jan 2001) N11
Pain on Motion 0.63 0.51 0.70 0.60
Pain at Rest 0.83 0.81 0.81 0.86
Ability to walk without significant pain 0.74 0.87 0.71 N/C
Other functional limitations 0.71 0.68 0.68 0.74
Abnormal joint 0.75 0.69 0.78 0.82
Potential for progression 0.38 0.25 0.56 0.70
Threat to role independence 0.63 0.70 0.75 0.82

15
Validation of Hip and Knee PCS
Study 1
Surgeon Assessment PCS VAS
Conner-Spady et al. Canadian Journal of Surgery
47, 39-46, 2004
Study 2
Surgeon Assessment PCS WOMAC
Conner-Spady et al. Intl Journal of Tech
Assessment in Health Care 20, 509-515, 2004
Study 3
Surgeon Patient Assessment
16
Medical Priority Referral Scores (PRS)
  • Objective Improve fairness
  • To develop priority-setting referral tools for
    use by primary care providers when referring to
    medical sub-specialties
  • To standardize referral information exchange

17
WCWL - PRS
  • Medical Specialties Chosen- Stage
  • Rheumatology Published, implementable
  • Gastroenterology B version tested with GI
  • Geriatrics B version testing pending
  • Nephrology B version testing pending
  • Arthritis Care Research 63(2), Feb 2011
    231-239

18
Medical PRS Methodology
  • Comprehensive literature synthesis
  • Two, two-day clinical deliberative processes
  • Discuss actual case scenarios rank order using
    clinical judgment
  • Identify emergency situations
  • Distill criteria that assess urgency of referral
  • Assign weights
  • Compare clinical ranking with PRS ranking

19
Deliberative Panel Set-up Support
  • Five specialists
  • Four family physicians
  • One nurse practitioner
  • One specialist as co-chair
  • One general practitioner as co-chair
  • Facilitator Dr. Ray Naden (NewZealand)
  • 1,000 minds Software

20
Results Rheumatology PRS
DOMAINS (3)
Current state of patient
Potential/ threat of progression
Delta benefit
CRITERIA (8)
Self reliance/ independence
Limit to usual role/work
Pain
Currently receiving steroids
Complexity management /risk due to comorbidities
Inflammatory markers
Evidence progressive major organ involvement
Evidence of active inflammatory arthritis
LEVELS
4
4
2
3
2
2
2
3
21
Rheumatology Priority Score Weights
/100
1. Self reliance/independence No significant or meaningful impact Significant or meaningful impact but not requiring assistance Requiring increased assistance in current environment At risk of recently requiring increased level of care in new environment 0.0 6.1 7.6 20.2
2. Limitation to patients usual role/work likely related to reason for referral No significant or meaningful limitation to their usual role/work Limited or unable to fulfill the patients usual role/work gt6 months Some recent limitation to the patients usual role/work Recently unable to perform the patients usual role/work 0.0 3.8 8.4 14.1
3. Pain No significant pain or pain controlled effectively Pain is not effectively controlled 0.0 6.1
4. Receiving glucocorticosteroids for rheumatological condition No Yes lt25mg prednisone (or equivalent) per day Yes gt25mg prednisone (or equivalent) per day 0.0 4.9 12.9
22
Rheumatology Priority Score Weights
/100
5. Complexity of management or risk due to PRE-EXISTING comorbidities No Yes 0.0 8.4
6. Evidence of PROGRESSIVE major organ involvement probably related to reason for referral No Yes 0.0 20.5
7. Inflammatory markers ESR gt30 (Wintrobe) OR positive C-Reactive Protein, OR Platelet count gt400,000 x 109/L No or not assessed Yes 0.0 5.3
8. Active Inflammatory Arthritis features joint swelling OR morning stiffness ( gt60 mins) of the joints or spine OR metacarpal-phalangeal/metatarsal-phalangeal (MCP/MTP) joint involvement No (with or without ve Rheumatoid factor) Yes without Rheumatoid factor Yes with Rheumatoid factor 0.0 8.7 12.5
23
Managing Waiting Times for Scheduled Services
  • Question addressed
  • WCWL research program (Funded by AI-HS CIHR)
  • Appropriateness
  • Priority-setting
  • Maximum acceptable waiting times
  • Operations research and scheduling
  • Patient expectations
  • Should this patient be placed in the queue?
  • What is the correct order for the queue?
  • How long should this patient wait?
  • Can we offer a certain waiting time?
  • What can make the waiting time experience better?

24
Current Work of WCWL Investigators Focused on
Hip Knee Replacement
  • Appropriateness (Sub-project 1 Sanmartin)
  • Patient expectations (Sub-project 2 Spady)
  • Operations research scheduling (Sub-project 3
    Carter)
  • Successful sustainable WTMS (Sub-project 4
    Pomey)

25
Value Proposition of Deliverables
  • Appropriateness a shared decision aid of value
    to patients acceptability surgeons managing
    expectations of outcomes reducing variability
    managing supply-induced demand
  • Patient Expectations better understand manage
    the waiting time experience improve satisfaction
    with surgical outcomes inform deliberations
    around next available surgeon single-entry
    models

26
Value proposition of Deliverables
  • Operations Research Scheduling offer a
    definite date for surgery forecast the future
    better planning simulate impact of system
    changes perturbations
  • Waiting Time Management Strategies generalize
    successful sustainable innovations in access
    management
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