The article screening process is shown in the PRISMA flow diagram (Figure 1) and the PRISMA checklist is available as Additional file 3. The electronic search in the five bibliographic databases yielded 7543 records for the full review. This was reduced to 5346 after deduplication using EndNote citation management software. During the title and abstract screening process, 362 citations were deemed potentially eligible for the full review. Of these, 196 relevant citations were obtained from full article screening, and, among these, 105 simulation and modelling studies were rejected. After grouping the citations into different strategies for reducing waiting time, three systematic reviews and six original studies (one randomised trial, two quasi-experimental studies, two longitudinal follow up studies and one observational study) published after 2013 were included for the final analysis of this sub-review, given their focus on interventions relevant to managing patient referrals as a way to reduce waiting time for elective surgery. Three of the original studies were from Canada, with one each from USA, Israel and Australia; five of these investigated specific institution-based referrals. The summary of nine studies included is shown in Table 1.
Table 1. Summary of included studies
Characteristics
|
Number (n=9)
|
1. Publication year
|
|
2015
|
2 (22%)
|
2017
|
1(11%)
|
2018
|
3 (33%)
|
2019
|
3 (33%)
|
2. Country of research
|
|
Canada
|
3 (50%)
|
USA
|
1 (17%)
|
Israel
|
1 (17%)
|
Australia
|
1 (17%)
|
*Three systematic reviews are excluded
|
|
4. Study design
|
|
Observational studies
|
3 (33%)
|
Systematic reviews
|
3 (33%)
|
Quasi-experimental studies
|
2 (22%)
|
Experimental studies (randomised trial)
|
1 (11%)
|
5. Study setting
|
|
Institution
|
5 (80%)
|
Health system
|
1 (20%)
|
*Three systematic reviews are excluded
|
|
6. Surgery types
|
|
Elective surgery
|
4 (45%)
|
Orthopaedic surgery
|
1 (11%)
|
Neurosurgery
|
1 (11%)
|
Eye surgery
|
2 (22%)
|
Bariatric surgery
|
1 (11%)
|
Summary of included studies: Nine studies were included in this review. The characteristics of the included studies are summarised below and further details are given in Tables 2 and 3.
Of the three systematic reviews, one was a scoping review to describe strategies to reduce waiting times and the other two summarised existing evidence on increasing patient flow in elective care pathways.
Starting with the original studies;
Damani et al. (35) reported a quasi-experimental study comparing a historical cohort (2397 patients recruited from 1 June 2011 to 1 June 2012) and a prospective cohort (2282 patients from 1 September 2013 to 1 September 2014) to assess the effects of a single-entry model (SEM) of referral to the next-available surgeon for total joint replacement surgeries in Canada. The results showed that the variability of waiting times among surgeons was reduced by 3.7 and 4.3 weeks for hip and knee replacements, respectively and there was a 5.6% increase in patients operated within the benchmark period.
Gabbay et al. (36) reported a quasi-experimental study with a historical and prospective study approach to evaluate the performance of a referral triage system through 2015 in Israel. They found that 44.4% of cancelled surgeries could have been prevented by a preoperative clinic visit and concluded that using a pre-operative triage system in referral letters for scheduling surgery could minimize both patient time and physician time prior to surgery.
Coyle et al. (37) reported a pragmatic, blinded, randomized trials with 227 consecutive eligible participants with an elective lumbar condition who were referred for consultation with a spine surgeon in Canada. Reprioritizing patients with a questionnaire reduced wait times for consultation appointments for patients who were eventually deemed to be surgical candidates. The odds of seeing a surgical candidate within the acceptable time frame of 3 months were 5.4 times greater for the intervention group. The authors concluded that it may be worth adding simple questionnaires to clinical care practices to better triage these patients on waiting lists.
Logvinov et al. (38) reported a survey of patients’ choices for the maximum waiting time sufficient to discuss having another surgeon perform the procedure in USA. There were 135 respondents from 2011 to 2016. The results indicated that the average patient would want to discuss the option of having another surgeon perform their procedure with the surgical team even if the wait with their currently assigned surgeon would be 4 days or less.
Do et al. (39) reported a cross-sectional study with longitudinal follow-up conducted at two metropolitan public hospitals in Australia. A total of 400 sequential cataract referral letters were audited in August to September 2014 to benchmark against international prioritization tools. Results from the 12-15 months follow-up of these patients revealed that referrals for cataracts were poorly targeted, with almost half of all patients reviewed in the clinic not proceeding to surgery. The authors concluded that standardized referral templates may facilitate the improvement of referral pathways and shorten waiting times.
Diamant et al. (40) reported a retrospective study of the impact of patient and operational factors on waiting times for patients referred to a tertiary care centre in Canada for bariatric surgery between June 2008 and July 2011. The univariate and multivariate analyses showed that patients with active substance use and individuals who entered the program in more recent operational periods had longer wait times. They concluded that some patients could be identified at the time of referral as being at risk for longer wait times and that process-level decision-making for multistage bariatric surgical programs might affect timely access to treatment.
Turning to the reviews:
Bachelet et al. (41) reported a scoping review of studies of interventions that have been implemented to reduce waiting times for major elective surgeries. They searched six electronic databases up to December 2017 and included 12 eligible studies. They assessed the quality of the evidence with EPOC (The Cochrane Effective Practice and Organisation of Care) and GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) tools, and rated all studies as low in overall quality. They concluded that there is a need for multidimensional interventions based on prioritization strategies, and quality management improvements of the surgical pathways and improvements in the planning of the surgical schedule.
Damani et al. (42) reported a review of the influence of SEM on waiting time for adult elective surgical services. They included 11 articles found from searches of six electronic databases up to July 2016. The authors used the Downs and Black checklist to assess the overall quality of the included studies. The results revealed a potential ability for SEMs to improve timeliness and patient-centeredness of elective surgical services.
Finally, Ballini et al. (43) reported a Cochrane Review of the effectiveness of interventions aimed at reducing waiting times for both diagnostic and therapeutic elective care. Eight studies were eligible and the overall quality of the evidence for all outcomes, assessed using the GRADE tool, ranged from low to very low. The authors assessed risk of bias using EPOC criteria. They found that interventions involving the provision of more accessible services (open access or direct booking/referral) were likely to be effective.
Risk of bias in included studies: All included studies complied with the eligibility criteria for this review. The quality of evidence in the included articles were measured using the most appropriate of three tools: ROBINS-I Cochrane risk of bias tool (5 studies); AMSTAR 2 (3 systematic reviews) and CASP for cohort studies (1 study).
ROBINS-I: Of the five studies, lower risk of bias in overall was found for the randomised trial (37). The other four studies were assessed as having medium risk of bias overall (35, 36, 39, 40). The details of the ROBINS-I evaluation are shown in Figure 2 and Figure 3.
One study used randomisation of participants (37). The remaining studies had low to moderate bias due to confounding for baseline characteristics of the two groups (35, 36, 39, 40). Since all patients in the selected cohort were included in all studies (without sampling), none of the studies had significant bias in their selection of participants for the study. In most studies, patient data were extracted from regular administrative records, except for one study which was rated with moderate risk of bias due to missing data (40). Bias in classification of the intervention was low in all studies, since the interventions were implemented as pre-test post-test design methods, where participants were not aware of the prioritisation scoring at the clinics. The outcome variable included in many studies is a time measurement associated with the waiting time, which was considered to be unbiased.
AMSTAR 2: One of three includes reviews was rated as high quality overall (43) and the other two were rated as moderate (35, 41). All review protocols had been registered and the reviews presented adequate searches for literature in relevant databases. All three reviews had assessed risk of bias in their included studies and considered this when interpreting the results. Estimates of meta-analysis and assessment of publication bias was not applicable for any of the reviews. Our ratings for each domain for the AMSTAR 2 tool are shown in Table 4.
CASP tool: A single study was assessed using the CASP checklist and the authors had reported important confounding factors for the study (38).
Table 2: Study characteristics of the seven original research articles included for the review with the overall risk of bias evaluation
Author and year
|
Country
|
Research method
|
Elective surgery
|
Objectives
|
Research setting
|
Participants, Research period, and intervention
|
Conclusions & recommendations
|
Risk of Bias*
|
Damani et al., (36)
|
Canada
|
Quasi-experimental approach with pre-post cohort design
|
Total knee/hip replacement (TKR) surgery
|
To evaluate
waiting time variations among surgeons,
proportion of patients receiving surgery within benchmark,
Influence across five dimensions of quality of care based on system- level and patient- centred outcomes (Quality accessibility, acceptability, appropriateness, effectiveness and safety).
|
Provincial health authority
|
Data were collected both before (June 2011-June 2012) and after implementation (September 3013-September 2014). Improve patient access to surgery by distributing referrals to the surgeon with shortest waiting time (next- available surgeon) and increase the proportion of patients treated within benchmark.
|
Intervention helped to improve accessibility by reducing waiting time variability among surgeons, all waiting times for TKR and increasing proportion of TKR within benchmark (5.9%).
|
ROBINS-I Moderate
|
Gabby et al., (37)
|
Israel
|
Quasi experimental approach with historical prospective study
|
Cataract surgery
|
To evaluate the efficiency of referral triage system which schedules most cataract patients to surgery based on referral letters, with surgery done immediately following the preoperative examination.
|
A Tertiary referral hospital
|
Evaluated the performance of the new referral triage system (2015, 12 months) by studying the reason for day-of surgery cancelations against retrospective system.
|
The novel approach of preoperative triage using referral letters for scheduling surgery, thus minimizing both patient and physician time prior to surgery and direct referral could shorten both costs and time to surgery.
|
ROBINS-I Moderate
|
Coyle et al., (38)
|
Canada
|
prospective, blinded, randomized controlled study
|
Neurosurgery; Elective Lumbar Spinal Surgery
|
To evaluate whether a self-administered 3-item questionnaire (3IQ) could reprioritize referral appointments and reduce wait times.
|
Canadian academic tertiary care centre
|
280 patients included within 24 months. Randomly assigned to surgeon triaged and patient triaged two groups, assessed for re-prioritisation status and the waiting time.
|
Reduced the waiting time of intervention group and to identify non-surgical candidates for appropriate managements. Demonstrated the benefit of patient-reported assessments in prioritisation.
|
ROBINS-I Low
|
Author and year
|
Country
|
Research method
|
Elective surgery
|
Objectives
|
Research setting
|
Research period and intervention
|
Conclusions & recommendations
|
Risk of Bias
|
Do et al., (40)
|
Australia
|
Cross-sectional study with longitudinal follow-up
|
Cataract surgery
|
To determine the content and diagnostic accuracy of cataract referral letters and assessed whether referral information had sufficient detail to triage patients and inform surgical prioritization.
|
Two metropolitan public hospitals
|
A review of referral letters and hospital medical records was undertaken for a total of 400 (2014). Reviewed same after 1 year.
|
Current referral letters do not have sufficient detail to inform prioritization, and any efforts to prioritize waiting lists will require standardization of cataract referrals. Development of standard referral templates and resources to triage referrals may improve access to surgical services in a timely manner.
|
ROBINS-I Moderate
|
Loginov et al., (39)
|
USA
|
Observational study
|
Elective surgery
|
To examine patient perspectives on surgical case scheduling, referral and wait time.
|
Mayo Clinic
|
135 respondents completed the survey (2011-2016). The survey had three attributes; patient desired maximum waiting time, choice of date and option to change the surgeon.
|
There was a positive association between the maximum waiting times sufficient to discuss having another surgeon perform the procedure.
|
CASP
Moderate
|
Diamant et al., (41)
|
Canada
|
Retrospective study
|
Bariatric surgery
|
To examine the impact of patient and operational factors on wait times in a multidisciplinary bariatric surgery program.
|
Toronto Western Hospital
|
1664 referred patients included for the survey (June 2008-July 2011). Waiting time associations screened for the 724 who underwent surgery.
|
Specific patient profiles and longer waiting are associated. Waiting time did not depend on BMI, age, sex and distance from the bariatric centre. Substance use was associated with longer preoperative evaluation.
Certain types of patients should be identified early in the referral process.
|
ROBINS-I Moderate
|
*Risk of bias in intervention studies were assessed using ROBINS-I tool and observational study was assessed with relevant CASP checklists. Overall quality measurement was reported considering the all risk of bias domains for the particular research.
Table 3: Study characteristics of the three systematic reviews included for the review
Author and year
|
Objectives of the systematic review
|
Search criteria
|
No of eligible articles and study designs*
|
Countries of included articles
|
Conclusions (%) & recommendations
|
Data sources
|
Search date and search period
|
Languages
|
RI
|
NRI
|
OB
|
Bachelet et al., (42)
|
Scoping review to identify and describe the interventions that have been implemented to reduce waiting times for major elective surgery and to synthesize the best available evidence on the effectiveness of some interventions that were prioritized by our ministerial counterpart
|
MEDLINE/PubMed, EMBASE, Cochrane Library, SciELO, DARE‐HTA, and Google Scholar
|
All articles up to 2017 were searched in December 2017
|
Only English and Spanish
|
1
|
6
|
5
|
Canada, Costa Rica, UK, Spain, Nordic countries
|
All the studies had methodological limitations. According to the evidence found for this review, interventions most likely should be multidimensional, with prioritization strategies on the waiting lists to incorporate equity criteria, together with quality management improvements of the surgical pathways and the use of operating rooms, as well as improvements in the planning of the surgical schedule.
|
Damani et al., (43)
|
To review and summarise existing research evidence on the scope, use and implementation of SEMs for elective surgical services, specifically with respect to the influence of SEMs on patient flow and waiting times for elective procedures in adults and acceptability of SEMs to patients and providers (general practitioners (GPs) and surgeons).
|
MEDLINE, EMBASE, CINAHL, the Cochrane Database for Systematic Reviews, CENTRAL (Cochrane Central Registry of Controlled Trials) and Abstract Business Information (ABI)/Inform
|
All articles up to July 2016 was searched in June 2016
|
No restrictions
|
0
|
5
|
6
|
Canada, UK, Australia
|
This review demonstrates a potential ability for SEMs to improve timeliness and patient-centeredness of elective services; however, the small number of low quality studies available does not support firm conclusions about the effectiveness of SEMs to improve access.
|
Author and year
|
Objectives of the systematic review
|
Search criteria
|
No of eligible articles
|
Countries of included articles
|
Conclusions & recommendations
|
Data sources
|
Search date and search period
|
Languages
|
RI
|
NRI
|
OB
|
Ballini et al., (44)
|
To assess the effectiveness of interventions aimed at reducing waiting times for elective care, both diagnostic and therapeutic.
|
Cochrane, MEDLINE, EMBASE, CINAHL, ABI Inform, the Canadian Research Index, The Science, Social Sciences and Humanities Citation Indexes, Pro quest, Trial Registries, Grey literature
|
All up to 2013
|
No restriction
|
3
|
5
|
0
|
Not reported
|
As only a handful of low-quality studies are presently available, it was unable to draw any firm conclusions about the effectiveness of the evaluated interventions in reducing waiting times. However, interventions involving the provision of more accessible services (open access or direct booking/referral) show some promise.
|
*RI: Randomised Controlled Interventions, NRI: Non Randomised Controlled Interventions, OB: Observational studies
Table 4: AMSTAR 2 critical appraisal tool ratings for critical domains and overall confidence for risk of bias in included systematic review studies
Citation
|
Protocol registered
|
Adequacy of the literature search
|
Justification for excluding individual studies
|
Risk of bias from individual studies
|
Appropriateness of meta-analytical methods
|
Consideration of risk of bias when interpreting the results
|
Assessment of presence and likely impact of publication bias
|
Rating overall confidence
|
Bachlete et al. (42)
|
Partial Yes
|
Partial Yes
|
Yes
|
Partial Yes
|
NA
|
Yes
|
NA
|
Moderate
|
Ballini et al., (44)
|
Yes
|
Yes
|
Yes
|
Yes
|
NA
|
Yes
|
NA
|
High
|
Damani et al., (52)
|
Partial Yes
|
Yes
|
Yes
|
Yes
|
NA
|
Yes
|
NA
|
Moderate
|