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 2Specialist 3 Misdiagnosis / do not qualify Consultation Surgery Some do not qualify Some are severe Some wait

Patient Specialist 3 Patient Specialist 2 Patient Specialist 1 Patient Current State of Waiting

Patient Specialist 1 Patient Specialist 2 Patient 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 Patient Specialist 1 Patient Specialist 1 Patient Specialist 2 Patient 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 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?