Tuesday, September 07, 2004

Wait List Woes II....
The single-payer crusader, in response to my earlier post sent me a link about waiting times and how they "not always a bad thing": Tackling Excessive Waiting Times for Elective Surgery: A Comparison of Policies in Twelve OECD Countries
It was educational to find out that 38 percent of patients in the United Kingdom had a wait time of over four months for elective surgery. The authors think that wait lists help maintain the "optimum rate of surgery". If no waiting list existed, their reasoning goes, there would be an excess of surgical capacity, which is expensive. There are some charts which give the ideal rate of surgery as when the marginal cost equals the marginal benefit. There are also mechanisms both from a supply side (increase capacity or start some production-based incentives) and a demand side (raising requirements to be on the list.) The increased use of outpatient surgery is advocated, but with caution:
In the last twenty years there has been a steady growth in the share of surgery carried out by daysurgery in many countries, thanks mainly to technological and medical innovations, such as less invasive surgery and better anaesthetics. Day-surgery is beneficial because it reduces the unit cost of treatment, which is driven by the length of stay. For a given endowment of beds, the availability of less invasive surgery can increase the volume of treatments performed and free up hospital beds. However, if the increase in day-surgery utilisation is accompanied by a contemporaneous reduction in the number of hospitals beds (as in most OECD countries), then the net impact on activity may be lessened. Moreover, less invasive and safer treatments raise the net benefits for the patient, making the procedures more desirable. That is likely to lead an increase in demand, especially for groups such as the very elderly, for whom there would otherwise be counter-indications for invasive surgery. The final effect on waiting times is then indeterminate.
Another problem arises since most of the minimally-invasive outpatient surgery procedures require the use of expensive equipment. The expense of this may trump any LOS gains realized.
The authors also advocate wait lists as a means to stabilize surgical demand over time. That is, every system should have an "emergency buffer" such as the extra unused OR or the extra CRNA around. Not very efficient but very useful when the ruptured aortic aneurysm shows up. The wait list is used as a "ready reserve" of patients which can fill up a slow day in the OR.
The darker side of wait-lists can be found in this article:
Risk of emergency admission while awaiting elective cholecystectomy

Waiting lists are a common tool for managing access to elective surgery. However, little evidence is available on the health impact of delaying surgery for various conditions. Other than mortality, adverse events experienced by patients while on a waiting list have not been systematically examined. Without these data, appropriate access time for surgery must be determined on the basis of expert opinion.
When treatment is delayed, the condition of a patient on a surgical waiting list may deteriorate and require urgent medical attention. In this case, emergency admission for the awaited procedure may be regarded as an adverse effect of waiting. Also, routine operating room activity may be seriously disrupted by unexpected nonelective admissions of patients on waiting lists.

In patients with biliary colic caused by cholelithiasis, extended treatment delays may increase the probability that the patient will be admitted for delayed cholecystectomy as an emergency case. Emergency admission may be associated with more frequent or more severe attacks of biliary colic or other biliary complications such as acute cholecystitis, obstructive jaundice, cholangitis or pancreatitis. However, little is known about the relationship between time spent on a waiting list and the risk of emergency admission in these patients....

The median length of stay on the list was 6 weeks. However, there was considerable variation in individual waiting times. The probability of undergoing elective surgery increased rapidly from 25% within 3 weeks of the last clinic visit to 50% at 6 weeks and 75% at 10 weeks, and then gradually reached a plateau. Although 90% of patients underwent surgery by 17 weeks, the remaining 10% waited another 1 to 3 weeks (total 18–52 weeks) for their operation.....

the weekly emergency admission rate increased from 0.8 to 5.7 per 100 patients from the first 4 weeks to the interval of 40-52 weeks. When adjusted for sex, age, enrolment period and surgeon volume, the emergency admission rate was more than 1.5 times higher after 20 weeks, 2 times higher after 28 weeks and 7 times higher after 40 weeks relative to the first 4 weeks of waiting-list time.

And it appears that need or chronology played little role in determining the waitlists of some surgeons:
Surgeons with a low volume of cholecystectomies (less than 20 per year) operated on the majority of patients with extended delays. In general, low-volume surgeons had a primary interest in surgical oncology. This may explain the order in which their patients accessed cholecystectomy during the waiting period.
No joke.
If wait-lists are an unavoidable, even desirable, effect of single-payer systems, will the population at large in America buy into it? I doubt it.
Cross-posted at Galen's Log
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