Waiting lists for surgery

Surgical waiting lists are seen by many as epitomizing the shortcomings of our public health care system. Yet, they can also be interpreted as being the result of a societal compromise between the founders’ promise of universal access to care and the reality of currently committed resources. Regardless of one’s perception, the debate about the “appropriate length” of a surgical waiting list has, arguably, become a fixture of everyday Canadian life.

The goal of the report by Taylor and colleagues in this issue1 is to describe the building of a score to manage general surgery waiting lists. The difficulty in devising such a tool lies in the complex analysis of clinical surgical judgement, the subjective evaluation of patient suffering and the need for multidisciplinary politically astute consensus. The Western Canada Waiting List Project (applied here to general surgery) was devised with just these issues in mind.

Many previous efforts at describing surgical waiting list management have been based on physician surveys or consensus, and usually have aimed to determine “acceptable” (and “unacceptable”) waiting times according to theoretical disease states. More recently, however, efforts have been made to more accurately document actual waiting times quantitatively.2 In a survey of 62 surgeons, Simunovic and colleagues3 described median waiting times from diagnosis to operation for 1456 Canadian cancer patients, concluding that many were experiencing “significant delays to treatment.” Another report related that 3-month delays in cardiac surgery were associated with subsequent decreased patient survival and quality of life.4

The aim of the study by Taylor and colleagues differs from such previous articles: it does not attempt to quantify waiting times; instead, it uses state-of-the-art research-based methodology and a concerted multidisciplinary clinical approach to propose an objective hierarchical management tool. The goal is thus not to determine an idyllic hierarchy of waiting times but rather to stratify or score patients on existing lists in a way that makes clinically reproducible sense by using objective criteria that are widely acceptable. Casting aside the date of listing by the proposed scheme may appear unorthodox but is in keeping with other contemporaneous efforts such as the Model End-Stage Liver Disease (MELD) score, which is currently being used by the American United Network for Organ Sharing to prioritize liver transplantation in the United States.5^,6

The report describes a regression model to explicitly relate surgical judgement to individual patient and disease criteria. The authors convincingly demonstrate many aspects of the reliability and validity of their scoring system.

The process and the science thus appear optimal, but an important question remains unanswered: Can the scoring tool be used effectively in everyday life? The application of a scoring approach to clinical practice in itself is not new. There are already several similar grading systems that are widely used and well known to clinicians, such as the APACHE score in intensive care unit patients or the Child–Turcotte–Pugh classification in cirrhotic patients.6 The current example, however, exhibits one major difference: the outcome against which the Western Canada Wait List Project tool is measured is not a clinical end point such as mortality or the need for hospital admission, but rather the clinical judgement of the surgeons themselves. It will therefore be crucial to further validate the tool against “firm” health outcomes before it can be widely accepted in clinical practice. Which brings up another point: the acceptability of the priority questionnaire by surgeons and, perhaps more importantly, by patients. Most surgeons would probably welcome the use of an objective tool to stratify the urgency of patient access to the operating room. However, one can only wonder how often a “surgeon override” clause might be used in daily practice when the imploring patient and the family are sitting across the busy surgeon’s desk. Also, patients, many of whom already feel disenfranchised from much health care decision-making, might believe that this allocation scheme removes yet another piece of what limited humanity remains in the health care system.

In spite of such operational issues, there is a real need for a prioritization tool such as the one described by Taylor and colleagues. In fact, the legal need for such a tool is about to be appraised in Quebec where a patient waiting for cardiac surgery died after his original operation had been allegedly postponed because of an illegal nursing strike.