Los Angeles, London, New Delhi, Singapore (June 19, 2008) ¯ Health-care system constraints combined with a lack of a uniform referral process are leaving Ontario physicians brokering which patients are in greatest need of hip and knee replacement, a study led by a St. Michael's Hospital researcher funded by the Canadian Institutes of Health Research has revealed. The variability in this process means not everyone who needs this surgery will actually get surgery.
"Findings from our study suggest several system factors are shifting the onus to physicians and surgeons to prioritize which candidates will receive hip and knee replacement," said lead author Pamela Hudak, a researcher in the Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital. "Physicians appear to adjust their criteria, often on a case-by-case basis, to identify which patients will be referred for or, in the case of surgeons, offered surgery. Ultimately this results in a varied approach in determining the best candidates, leaving many eligible and suitable candidates on waiting lists or to manage their problems as best they can with conservative approaches like medications."
The study, conducted by a team of researchers from across the University of Toronto and published last week in the journal Medical Decision Making, published by SAGE, examined the impact of patient characteristics, including age, weight/obesity, comorbidity and perioperative risk, and gender and caretaker roles in the decision-making process of 18 family physicians, 15 rheumatologists and 17 orthopedic surgeons from across Ontario.
"Although we expected these characteristics to affect candidates chosen for surgery, we did not expect the significant impact system constraints, such as lack of home care and postoperative support, waiting lists and access to operating rooms, would have on the decision-making process," Hudak explained. "Waiting lists prompted some physicians to refer patients earlier than normal while the lack of available home care and postoperative support, crucial for hip and knee replacement patients, prevented other physicians from referring patients. Beyond these limitations, surgeons also said they would take on more cases if more operating room time was available. These limiting factors can then affect how surgeons and physicians prioritize their patients, especially without common guidelines."
Based on these restrictions, researchers found that not only are physicians required to identify candidates for surgery but have become medical brokers whereby they are prioritizing and negotiating which candidates are the best candidates for the procedures.
"A lack of shared understanding among physician groups in our study about whom and when to refer patients suggests that they are currently operating with less than optimal tools for appropriate brokering," said the study authors. "More explicit information is required about whom to prioritize and how to ensure that prioritized candidates make their way through the system in a timely fashion."
The article "Not Everyone Who Needs One Is Going to Get One: The Influence of Medical Brokering on Patient Candidacy for Total Joint Arthroplasty" by Pamela L. Hudak, Pamela Grassau, Richard H. Glazier, Gillian Hawker, Hans Kreder, Peter Coyte, Nizar Mahomed, and James G. Wright is published Online First and is available FREE for a limited time at http://mdm.sagepub.com/cgi/rapidpdf/0272989X08318468v1.
Medical Decision Making (MDM) offers rigorous and systematic approaches to decision making that are designed to improve the health and clinical care of individuals and to assist with health policy development. The Journal presents theoretical, statistical, and modeling techniques and methods from a variety of disciplines, including decision psychology, health economics, clinical epidemiology, and evidence synthesis. MDM promotes understanding of human decision-making processes so that individuals can make more informed and satisfying choices regarding their health. MDM's 2007 Impact Factor increased 26% from 2006 to 2.196.
St. Michael's Hospital is a large and vibrant Catholic teaching and research hospital in the heart of Toronto. Affiliated with the University of Toronto, St. Michael's Hospital leads with innovation, and serves with compassion. Renowned for providing exceptional patient care, St. Michael's Hospital is a regional trauma centre and downtown Toronto's designated trauma centre for adults.
SAGE is a leading international publisher of journals, books, and electronic media for academic, educational, and professional markets. Since 1965, SAGE has helped inform and educate a global community of scholars, practitioners, researchers, and students spanning a wide range of subject areas including business, humanities, social sciences, and science, technology and medicine. A privately owned corporation, SAGE has principal offices in Los Angeles, London, New Delhi, and Singapore. www.sagepub.com
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Medical Decision Making