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• W2103292402 abstract "Lengthening queues and deaths among patients on waiting lists for coronary artery bypass graft surgery (CABG) have repeatedly sparked professional and public concern since the problem first emerged in Canada during the late 1980s. Although the risk of dying while awaiting CABG is very low, patients carry myriad burdens — social, psychological and financial — when the relief of disabling cardiac symptoms is delayed. Moreover, when waiting lists are long the condition of some patients in the elective queue will eventually destabilize, necessitating urgent intervention. An inefficient vicious cycle sets in whereby more and more elective cases are unpredictably “bumped” to make way for cases that have become urgent. More generally, long waiting lists are signposts for a supply–demand mismatch, and immediately raise the question, Is the current level of service provision too low? The existence of a queue does not in itself answer this question in the affirmative. Imagine, for example, a clinical service that was once in short supply, leading to long queues. Funding and capacity steadily increase, leading to a new equilibrium between supply and demand. The result would be a long but stable queue, persisting as an epiphenomenon of past problems rather than current shortfalls. Shortening the queue would require a one-time increase in throughput, not a fixed or recurrent increase in population-based rates of service. On the other hand, if a queue for a given service is growing steadily, and if most patients in that queue will achieve clear-cut health benefits from that service, then there is a strong prima facie case for service expansion. This thinking underpins a fascinating article in this issue by Dr. George A. Fox and colleagues (page 1137), in which they benchmark the provision of CABG for Newfoundland and Labrador. The authors apply explicit appropriateness criteria developed in 1991 by a Canadian expert panel. Using the Delphi method developed by RAND Corporation, this panel rated hundreds of surgical indications representing different combinations and permutations of the clinical factors that determine the expected net benefits of CABG. Of 338 patients in Newfoundland and Labrador who underwent CABG in the fiscal year 1994–95, the team matched over 99% to surgical indications for which the panelists judged the net benefits sufficient to make the procedure worth while. Because appropriateness ratings by expert panels assess the abstract potential for net benefit, they tend to err on the side of intervention. The Canadian expert panel accordingly had rerated each “appropriate” surgical indication on a “necessity” scale. A high necessity rating for an indication would mean that failure to offer surgery to such patients might be regarded as malpractice. Fully 94% of the CABG cases assessed by Fox and colleagues met these more stringent criteria. Having validated the clinical judgement of cardiologists and cardiac surgeons at their centre, the authors examined waiting times and patient throughput. They documented delays that exceeded detailed guidelines suggested by an Ontario expert panel, and also found that whereas 391 patients were referred for surgery, only 338 underwent the procedure in 1994–95. This confirmed that there was growth in an already excessive queue of patients who would benefit from surgery. Fox and colleagues also assessed the patients undergoing angiography who had not been accepted for CABG and identified an additional 31 patients who met neEditorial" @default.
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• W2103292402 title "Benchmarking the provision of coronary artery surgery." @default.
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