Elective Surgical Procedures; Time Management; Health Systems

ABSTRACT

  1. OBJECTIVES: To support decision-making strategies in public policies related to queue management for elective surgeries, presenting evidence from scientific research both globally and locally, with options to address queue management for elective surgical procedures and considerations regarding their Implementation.
  2. METHODS: A systematic search was carried out in a wide range of databases, complying with reviews.
  3. RESULTS: The increase in investments in public health is a truly effective solution to expand services and provide an adequate supply for performing surgeries. However, it is always possible to qualify and organize the demand for procedures. The study on-screen identified eight systematic reviews that allowed the synthesis of eight interventions to qualify demand and increase supply.
  4. CONCLUSION: It is proposed to achieve a balance between the two components: supply versus demand.

INTRODUCTION

It is considered that the waiting time for solving health problems is a critical element in universal health systems as it is an indicator of the provision of services to the population.

1 The excessive waiting time to undergo elective surgery can have unfavorable implications, both for the patient and their family, as for the health professional, for the hospital, the health system, and, finally, for society itself. Two for the patient, this waiting, in addition to the natural anguish for not having their problem properly treated, can cause complications, such as the worsening of their initial state and even death.

2 For the health professional and for the hospital, this wait brings greater complexity to the surgical procedure, with implications for cost-effectiveness, as the delay directly influences the clinical outcome, increases the costs of procedures, and increases the length of stay. The waiting time for elective surgery varies according to several factors such as the offer of specialized services, work process in health units, demand characteristics, number of available beds, less or greater experience of the surgical team, installed capacity of operating rooms in the network public, cancellation of elective surgeries due to the need for beds for urgent/emergency surgeries, the definition of the hospital profile, type of remuneration of health professionals, formation of care networks/lines of care to meet demand, population coverage policy, criteria for prioritizing patients in relation to clinical and social conditions, and effectiveness of the management of the health services system in both pre-hospital, hospital, and post-hospital conditions.

3 Unfortunately, the waiting time for elective surgery has not become shorter in recent years; on the contrary, the trend is for the situation to worsen.

4 In Australia, the health services system is a mix of public and private. The patient’s surgical flow begins with the assessment by the general practitioner, who can refer the patient to specialized consultations. Once the surgical approach is established, the patient enters a single waiting list, which determines the clinical priority of surgical treatment. One in New Zealand, the introduction of scoring tools for prioritizing elective surgeries occurred in association with health reforms in 1993.

  1. This prioritization takes place through a system composed of criteria that consider the ethical basis, risks, and clinical benefits.

In addition to specific surgical criteria that were developed through literature review and protocols by consensus among experts 5, a management tool was developed aimed at integrating the criteria to establish priorities in the waiting list. 1.5 in Canada, patients are referred by the general practitioner. Coverage is universal, funding is public, and states are free to establish criteria for entry into program one. Two strategies are used to manage waiting lists for elective surgeries: (i) the first is the Western Canada Waiting List Investigators (WCWL), which develops waiting list management protocols for five areas (Children’s Mental Health, Breast Surgery). Cataract, general surgery, hip/knee prosthesis  General Surgery Instruments and MRI exams), each Protocol was developed by a panel of healthcare professionals, composed of family physicians, specialist physicians, healthcare administrators, and researchers relevant to each area6, and (ii) the second is the Ontario Wait Times Strategy (OWTS), which aims to reduce wait times in five areas (cancer, cardiac interventions, joint replacement, vision restoration, and diagnostic imaging), improving management efficiency by setting appropriate wait time targets and developing a system to prioritize patients through clinical needs. 1 in England, the emphasis was on improving the management of elective surgery queues from the general practitioner, seeking to improve the experience with the use of guidelines and protocols. This strategy qualified referrals to surgical services, in particular, improved the definition of diagnosis in the period prior to referral to the surgeon, as well as the performance and opinion of preoperative tests. 1 In Portugal, patients registered for surgery can follow their situation on the waiting lists. Through the Integrated Management System for Surgery Subscribers Program (e-SIGIC), it is possible, on the Internet, to know the position that it occupies on the List, as well as the waiting time scheduled to perform the surgical intervention. 1 In France, waiting lists for surgeries are relatively small, as there is a high supply of hospital beds. 1 Access to private beds expands the offer beyond the capacity installed exclusively by the public network. 1 In Brazil, the control of waiting lists for surgery is performed through internal agendas or spreadsheets managed by the medical specialties in each hospital. 2 This format of regulation is an organizational barrier, as information is not unified, without transparency, retained at the operational level, and the possibility of planning/managing health services in the care network is lost.

In April 2017, the Ministry of Health determined the unification of the queue for elective surgeries. The National Regulation System (SISREG) software was made available to states and municipalities to draw a preliminary overview of surgeries awaiting completion. However, it has not yet been implemented, mainly due to the low adherence to the program by local managers. Thus, the overview of systematic reviews on-screen aims to support the formulation and decision-making in public policies related to the topic, presenting evidence of scientific research both at a global and local level, with options to address queue management for elective surgical procedures and considerations regarding its Implementation.

METHODS

A systematic search was performed in the following databases: Medline (PubMed), The Cochrane Database of Systematic Reviews, Scopus, Center for Reviews and Dissemination (CARD), Lilacs, Cielo, Embase, Testimonios, Health System Evidence, ScienceDirect, Portal Saudi Based in Evidence, International Initiative for Impact Evaluation (3ie) and PROQUEST, in addition to gray literature (Google Academic). The search strategy was based on the identification of systematic reviews based on the terms:

DISCUSSION

Waiting lists arise when demand for elective procedures exceeds supply. Lack of supply may reflect low installed capacity or inefficient use of existing capacity. On the demand side, in short, we may be facing low-skilled demand. The main health policy instruments to reduce waiting times in lines are increased supply, qualification of demand, and strategies for their execution.

The management regarding the reduction of the waiting time of patients for elective surgery is different from country, region, and type of surgical specialty. Among the possibilities for managing queues for elective surgeries are 5.7-13 (i) demand qualification (single-entry model, restructuring of the work process, queue prioritization tools, and queue management conducted by the family doctor or general practitioner, and (ii) the increase in supply (payment for productivity, day or outpatient surgery, expansion of surgery services with the purchase of third-party services, and expansion of own/public surgical services).

Interventions that seek to eliminate or minimize waiting times by increasing supply are structuring. 7 Countries that have solved the problems of waiting times in a stable manner, such as France, Belgium, Germany, and Switzerland, expanded public services and/or private providers, paid based on the volume of surgeries, that is, increased financial investments, to actually solve the problem. It is known. However, that increasing funding for public health, in current times, goes through intense political disputes in society, with immediate effects on distributive budgetary conflicts, and the success of such goals depends, fundamentally, on being based on macroeconomic policies development, generators of economic and social growth. 15 Hence the need to equalize interventions between supply and demand – the synthesis idea of ​​this study, according to each context.

Expansion of surgical services with the purchase of private services

Outsourcing services is an option that involves expanding installed capacity by purchasing services from the private sector. In this regard, a synthesis of evidence carried out previously showed that increasing capacity by contracting services from the private sector helps to reduce the subjective expectations of patients, but without significantly reducing the waiting time for elective surgeries. Furthermore, private providers have their own criteria and tend to choose the type of services that can be performed most profitably. Strict contracts and careful monitoring are essential instruments to ensure that the private company meets the supply and quality standards required by the public system.

Expansion of own/public surgical services

The expansion of own/public surgical services involves strategic decision-making on budget investments, with the allocation of resources to increase the installed capacity of the public sector, especially in systemic points with greater bottlenecks.

The expansion of public health services is a definitive solution capable of generating care stability⁷. International comparisons suggest a significant and permanent association between the increase in public installed capacity (increase in hospital beds, hiring of specific health teams, and purchases of equipment and supplies) with a reduction in waiting time for surgical procedures. This strategy has been successfully employed in Canada, Denmark, and England.

CONCLUSION

Of the eight systematic reviews presented, the one that obtained the best rating by the AMSTAR criteria (11/11) was that by Ballina et al. 9, published by the Cochrane Collaboration in 2015, considered the gold standard institution in Systematic Review studies. The design of the primary studies was defined as an inclusion criterion, in which only randomized clinical trials, controlled studies before and after, and studies with interrupted time series were accepted. According to the Cochrane Collaboration, the three methodological designs would be able to demonstrate the level of effectiveness of the intervention, with implications for the consistency of the evidence.

The SR performed by Ballina et al. found eight primary studies – three were randomized clinical trials, and five were studies of interrupted time series, being evaluated: 135 primary care clinics, seven hospitals, and one patient day clinic9. Even so, the evidence found had a low or very low degree of recommendation, according to the GRADE criterion, and the interventions that proved to be promising were related to the expansion of access to elective services, structured and guaranteed through open scheduling or direct reservation on the List waiting for 18.

It should be noted that effectiveness parameters were also established related to the type of elective procedure, the installed capacity for its performance, as well as the prior definition of waiting times considered urgent (less than 30 days), semi-urgent (less than 90 days) and, not urgent (less than 360 days). There was a significant reduction in the waiting time for procedures considered semi-urgent. It can be seen, therefore, that the generalizability of the results found in this Overview of Systematic Reviews is low, but the ability to use it according to the loco-regional specificity is high, provided that some possibilities are evaluated, including new financing, logistics, and material resources, assistance profile of services, expertise and sufficiency of health professionals, and the governance capacity of the health system.