Biomedical subjects

Andrew D MacCormick

Publications and source records attributed to Andrew D MacCormick.

6 recordsLinked to original sources

PubMed2004

Priority assessment of patients for elective general surgery: game on?

BACKGROUND: Clinical priority assessment criteria (CPAC) are used to generate a score by which patients are prioritized and rationed for elective surgery. It is widely believed that surgeons elevate scores to ensure their patients' acceptance for elective surgery, colloquially called gaming. The purpose of the present paper was therefore to investigate whether there was a temporal trend to an increase in the assigned priority score from the inception of CPAC to the present. METHODS: Priority and weighted inlier equivalent separations (WIES) scores between 23 April 1999 and 23 July 2002 were collected for elective general surgical cases at Auckland Hospital. A total of 5440 cases was retrospectively analysed using multiple regression techniques. Priority score was included as the dependent variable and time as an independent variable. Any change in case complexity over that period was accounted for by including the WIES score as a covariate. Multiple regression was undertaken for the combined surgeons and for individuals. RESULTS: The combined model was statistically significant but accounted for only 17% of the priority score variance. An increase of one WIES unit leads to an increase of 2.7 in priority score (P=0.0001). The relationship of priority score with time was dependent on the surgeon performing the prioritization. However, only half the surgeons had individual models that indicated gaming. CONCLUSIONS: The results show that gaming is occurring but that not all surgeons participate in this. The difference between surgeons' participation in gaming is a potential source of practice variation in the prioritization process.

Elective Surgical Procedures↗

PubMed2003

Prioritizing patients for elective surgery: a systematic review.

BACKGROUND: Priority scoring tools are moot as means for dealing with burgeoning elective surgical waiting lists. There is ongoing development work in New Zealand, Canada and the UK. This emerging international perspective is invaluable in determining the application of these tools and addressing any pitfalls. METHODS: A systematic electronic literature review was performed. Information was also retrieved using a search of reference lists of all papers included in the review and contact with those who were involved in the development of such criteria. RESULTS: The ethical basis of prioritization differed among priority scoring tools and in a number was not stated. The majority of tools covered criteria for specific procedures. Delphi consensus methods and regression were the predominant methods for -deter-mining -specific criteria. Authors' opinions were the main source of generic criteria. Linear and non-linear models or matrices sum-mated criteria. CONCLUSION: There is debate over the ethical basis for prioritization. It is a concern that it is not addressed in many studies. The development of generic criteria showed a dearth of consensus approaches that represents a significant gap in our knowledge. On the aspects of summation and weighting, the impact of assumptions on the prioritization of patients may not have been fully explored.

Elective Surgical Procedures↗

PubMed2003

Waiting time thresholds: are they appropriate?

BACKGROUND: The introduction of health reforms in New Zealand included the setting of an arbitrary waiting time threshold of 6 months for surgery. The aim of the present study was to investigate the differences in waiting times for different diagnoses in elective general surgery, and the interplay between diagnoses and waiting time thresholds. METHODS: A survival curve analysis of 918 patients placed on the elective general surgical waiting lists was conducted. This was undertaken in a tertiary level hospital in New Zealand before the implementation of the waiting time thresholds. The difference between diagnoses of time waited for elective surgery (plotted on survival curves), and hazard function for patients waiting at 180, 360 and 540 days, was investigated. RESULTS: Survival curves for malignancy, cholelithiasis, hernias and anorectal disease were different on log-rank test (P < 0.001). Those with a diagnosis of malignancy show that at 180 days the hazard function was 0.0049 but by 360 days had dropped to zero. With hernias and anorectal disease, the drop to zero appeared to be delayed until 540 days; however, the confidence intervals at 360 days included zero. In the case of cholelithiasis, the hazard functions indicate surgery occurring until 540 days. CONCLUSIONS: There are different waiting time thresholds for different surgical illnesses. Setting a universal waiting time for elective surgery is not supported.

Cholelithiasis↗

PubMed2002

Prioritizing patients for elective surgery: clinical judgement summarized by a Linear Analogue Scale.

BACKGROUND: The New Zealand health reforms have resulted in the requirement that surgeons utilize Clinical Priority Access Criteria (CPAC) to ration patient access to elective surgery. The validity of the tools used as CPAC has been challenged. An alter-native tool, the Linear Analogue Scale (LAS), is therefore used in our institution. Our objectives were to determine the variables that influence the priority score generated using the LAS, and the length of time waited by patients awaiting general surgical procedures. METHODS: A cohort of 918 patients who were listed for elective general surgical procedures at Auckland Hospital, Auckland, New Zealand between 1 July 1998 and 31 March 1999 were studied. Patients were given a priority score generated using the LAS. For each patient, the time from assessment until his or her procedure was documented. Linear and logistic regression models were used to investigate variables (age, gender, diagnosis and surgical team) that influence priority score. Cox proportional hazards models were used to investigate variables (priority score, age, gender, and diagnosis) that influence the length of time waited. RESULTS: Graphical presentation showed a pattern of priority scores falling into 'bands' for different diagnoses. Diagnosis, and to a lesser extent surgical team, influenced priority score. Survival analysis showed 'time waited' to be influenced by priority score, diagnosis, and patient age and gender. CONCLUSION: The LAS may have a useful role in the difficult sphere of patient prioritization. Its strength lies in its simplicity. Further investigation of reliability and effect on patient outcomes is required.

Adolescent↗

PubMedDate not supplied

Necrotizing fasciitis: analysis of 48 cases in South Auckland, New Zealand.

BACKGROUND: To assess the presentation, management and risk factors for mortality in necrotizing fasciitis at Middlemore Hospital in South Auckland, New Zealand. METHODS: A retrospective review of the medical records of patients presenting to Middlemore Hospital over a 6-year period (1997-2002) with a diagnosis of necrotizing fasciitis. RESULTS: Forty eight patients were identified. There were 27 men and 21 women whose age ranged from 19 to 80 years (median 51 years) at presentation. Maori and Pacific Islanders accounted for 64% of total admissions despite making up only 31% of the referral population. Streptococcus Pyogenes was the most common bacterial isolate (54%). 31% of patients had polymicrobial infections. Sixty-two per cent of cases involved extremities. The median number of operations and length of stay were 4 and 31 days, respectively. Overall mortality was 29%. In multivariate analysis, delay in surgical intervention (P = 0.015) and diabetes mellitus (P = 0.023) were found to be associated with increased mortality. Ethnicity, sex, type of pathogen, site of infection and increasing age did not affect mortality. CONCLUSION: Necrotizing fasciitis remains a significant problem in our community especially in the Maori and Pacific population. Early surgical debridement decreases mortality rates.

Adult↗

PubMedDate not supplied

Judgment analysis of surgeons' prioritization of patients for elective general surgery.

BACKGROUND: Access to elective general surgery in New Zealand is governed by clinicians' judgment of priority using a visual analog scale (VAS). This has been criticized as lacking reliability and transparency. Our objective was to describe this judgment in terms of previously elicited cues. METHODS: We asked 60 general surgeons in New Zealand to assess patient vignettes using 8 VAS scales to determine priority. They then conducted judgment analysis to determine agreement between surgeons. Cluster analysis was performed to identify groups of surgeons who used different cues. Multiple regression for the combined surgeons was undertaken to determine the predictability of the 8-scale VAS. RESULTS: Agreement between surgeons was poor (ra=0.48). The cause of poor agreement was mostly due to poor consensus (G) between surgeons in how they weighted criteria. Using cluster analysis, we classified the surgeons into 2 groups: 1 took more account of quality of life and diagnosis, whereas the other group placed more weight on the influence of treatment. The 8-scale VAS showed good predictability in assigning a priority score (R2=0.66). DISCUSSION: The level of agreement reflects surgeons' practice variation. This is exemplified by 2 distinct surgeon groups that differ in how criteria were weighted.

Elective Surgical Procedures↗