Single-entry models: value and acceptability among

orthopaedic surgeons in Canada

March 28, 2012

Taming of the Queue

Pre-Conference Workshop

Zaheed Damani

Dr. Barbara Conner-Spady

Dr. Tom Noseworthy

Overview

Single-Entry Models: an introduction Patient views Surgeon views Critical success factors Discussion

Background on waiting times Access

Waiting times (WTs) are an issue in most health systems, particularly in universal health care (Siciliani & Hurst, 2003)

Demand > Supply WTs can be reduced

Many strategies exist, varying effects/results, no clear solution

Elective procedures Hip and Knee replacement; 26 wks

Current State of Waiting

Patient

GP

Patient

GP

Patient

GP

Patient

GP

Patient

GP

Patient

GP

Patient

GP

i.e. complaints of joint pain

Specialist 1 Specialist 2 Specialist 3

Misdiagnosis / do not qualify

Consultation

Surgery

•Some do not qualify

•Some are severe

•Some wait

Patient

Specialist 3

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Specialist 2

PatientPatient

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Specialist 1

Patient

Current State of Waiting

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Specialist 1

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Specialist 2

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Specialist 3

Patient

Single-entry models 1 line/10 tellers vs. 10 lines/10 tellers

Banks, Airlines, Restaurants, Health care?

A single queue Centralised intake/single point of entry Pooled list Triage/screening

Waiting lists pooled, patients treated by a pool of surgeons on a first come, first served basis, or adjusted for urgency

Example: Hip and Knee clinics Calgary, Edmonton, Red Deer Nova Scotia, Winnipeg

Patient

Specialist 3

Patient

Specialist 2

PatientPatient

Patient

Specialist 1

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Specialist 1

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Specialist 2

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Specialist 3

Patient

Profile: Edmonton Hip and Knee Clinic

Pooled list: Patients have the option of seeing the next-available surgeon, or a named surgeon of their choice

Single Entry: All patient referrals are sent to the H&K clinic

Triage: Referrals are evaluated for priority and urgency; sent to the appropriate surgeon

Surgeon conducts consult at the H&K Clinic Majority of surgeons participate

One-stop shop for patients awaiting H&KR

Evidence base Ten studies in the literature Currently employed in CAN/AUS/UK Promising evidence

Potential for equity, reduced WTs, costs, little patient impact

Not high level evidence – no RCT or comparative studies

Gaps / Motivation for this work: Questions remain about

acceptability among patients and clinicians

This is important to understand

Patient

Specialist 1

Patient

Specialist 2

Patient

Patient

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Specialist 3

Patient

Current knowledge about SEMs

The unspoken agreement…

SEMs currently in use: Patients need to agree to go through the same

door Surgeons need to be on board to receive them in

such a fashion, on the other side

What remains to be studied? What do both think about this? How can their acceptability of this model be

increased?

What have patients told us? Spady et al.

Focus groups conducted in Calgary, Winnipeg, Toronto, Halifax (n = 114)

Questionnaire administered as well Acceptability of being placed on a waiting list to be seen by the

next available orthopedic surgeon

Choice based on trust and reputation Virtually divided on seeing the next-available

Must be equally qualified and waiting time reduction of at least 1 month

Would be willing to see next-available if pain or urgency required it

What about surgeons?

Are single-entry models acceptable to orthopaedic surgeons receiving referrals for H&KR?

Under what conditions?

Study Methods

19 Experienced surgeons recruited 11 Alberta (8U/3R), 4 Manitoba (3U/1R), 4 Nova Scotia (4U) 11 Academic & 8 Community-based 15 Urban and 4 Rural

Semi-structured interviews (telephone) Structured and open-ended questions Thematic analysis used to code, classify and interpret the

findings 2 coders

Results

68% of surgeons accept patients from a pooled list

89% familiar with SEMs 84% initially rated as acceptable

93% among urban, 60% among rural

Between 30 – 42 unique themes discussed in each of the 6 open-ended questions

Acceptability was not universal; there are caveats

Results

Classified into 5 broader aggregate themes: Patient Experience

Ability to retain choice Evaluation Physician Involvement Management Resources

1. Physician Involvement Common to both rural and urban surgeons:

Continuity of Care Trust, relationship are important in surgery

Implication for outcomes Concerns with lack of continuity of care Pooling for surgery vs. consultation

Feeling reduced to a “technician”

Competence and trust among surgeons Optional participation / inclusion Concerns over the skill of those involved

Quality monitoring to improve performance

2. Management

Praise for Screening; concerns over case mix Appropriate for surgery; yield Minimum case-loads Urban vs. Rural

Pooling for consultation Vehement opposition to pooling for surgery Enables continuity of care

Calls for optional surgeon participation

Desire for autonomy to make clinical decisions, contribute to care path

3. Resources

Strong praise for staff / multidisciplinary team Improves patient care, experience Reduces demand on surgeons’ time

Concerns over funding To increase clinical capacity To maintain screening Balancing priorities (general vs. specialist)

Critical Success Factors Allow patients to retain an ability to choose Allow surgeons optional involvement; ability to

maintain choice, ability to make final clinical decisions (i.e. for surgery)

Centralised triage, intake and streamlined management is a must, with fair distribution and matching of cases to surgeons

Lists should never be pooled for surgery, only consults

Consistent, predictable funding to support screening, staff

Government commitment towards achieving agreed-upon benchmarks

Discussion

Surgeon opinions differ, generally in favour of SEMs / status quo; acceptability is not universal Rural vs urban

Critical success factors will enhance acceptability Consideration of these factors could improve existing SEMs Possible generalisability to other elective procedures

Findings consistent with literature 2 studies from the UK – spinal surgery and ophthalmology

Further research – GPs, policy makers Controlled studies

Thank you

Questions?

Surgeon Interviews

We asked 6 questions: What aspects of SEMs do you agree / disagree with? What factors/incentives would be important to you and your

patients to make single-entry models acceptable? What factors/circumstances would cause you to oppose

single-entry models? What kinds of practice characteristics or administrative

supports would be needed for the implementation of single-entry models?

If we were discussing the implementation of single-entry models in your practice, to what extent would you be in favour of implementing single-entry models?