Waiting list statistics. II: An estimate of inflation of waiting list length.

The discrepancy between the length of the waiting list and eventual admissions from the waiting list was investigated by comparing data from two different sources of routine statistics in the Oxford region. It was estimated that about 28% of the waiting list comprised patients who were not eventually admitted to hospital within the region.     

Waiting list statistics. III. Comparison of two measures of waiting times.

The length of time that patients spend on waiting lists is a topic of current concern. Calculating the proportion of patients who have been on a waiting list for a long time by taking a census of patients on the list at a single point in time will tend to yield a higher estimate than that obtained by calculating waiting times of patients admitted to hospital during a period of time. To illustrate this point the waiting times of patients in the Oxford region as measured by SBH 203 returns ("census" data) were compared with those as measured by the Hospital Activity Analysis ("event" data). As expected, the SBH 203 census returns showed a higher proportion of patients who had waited over a year compared with the "event" measure of all admissions. This difference, which is analagous to the difference between prevalence and incidence in epidemiology, should be considered when using data from these sources to calculate waiting times.     

Waiting list management in general practice: a review of orthopaedic patients.

OBJECTIVE: To review all patients on a current general practice orthopaedic waiting list for outpatient appointments with regard to accuracy of the list, clinical priority, and need for further radiological investigation before hospital attendance. DESIGN: Record review by one general practitioner and a radiologist, and discussion with patients of management alternatives. SETTING: Six partner city centre urban fund-holding general practice, list size 8651 (29% low deprivation payment status). SUBJECTS: 116 adults on an orthopaedic waiting list. MAIN OUTCOME MEASURES: List accuracy (patient details and status on waiting list); clinical priority (severity of condition); further investigations (results of tests after radiological review). RESULTS: 32 patients (28%) were removed from the waiting list because of inaccuracies. 14 patients were considered to be high priority and referred to other hospitals by utilising waiting list initiative funds. Of these patients, five agreed to referral to another hospital (treatment completed on average within three months of rereferral), six did not wish to be rereferred, and two did not attend to discuss the offer and remained on the original waiting list. One prioritised patient had further radiological investigations, was reassured, and was taken off the waiting list. 10 patients had further investigations. These resulted in six patients being referred to other hospitals, three being taken off the waiting list, and one seeking private care. CONCLUSIONS: Systematic review of patients on an orthopaedic waiting list of one general practice, though time consuming, led to the identification of inaccuracies in the list and changes in management. Costs need further evaluation, but if the findings occur widely substantial benefits could be achieved for patients.     

Equity of access to renal transplant waiting list and renal transplantation in Scotland: cohort study

Objective To examine the access to the renal transplant waiting list and renal transplantation in Scotland.Design Cohort study.Setting Renal and transplant units in Scotland.Participants 4523 adults starting renal replacement therapy in Scotland between 1 January 1989 and 31 December 1999.Main outcome measures Impact of age, sex, social deprivation, primary renal disease, renal or transplant unit, and geography on access to the waiting list and renal transplantation.Results 1736 of 4523 (38.4%) patients were placed on the waiting list for renal transplantation and 1095 (24.2%) underwent transplantation up to 31 December 2000, the end of the study period. Patients were less likely to be placed on the list if they were female, older, had diabetes, were in a high deprivation category, and were treated in a renal unit in a hospital with no transplant unit. Patients living furthest away from the transplant centre were listed more quickly. The only factors governing access to transplantation once on the list were age, primary renal disease, and year of listing. A significant centre effect was found in access to the waiting list and renal transplantation.Conclusions A major disparity exists in access to the renal transplant waiting list and renal transplantation in Scotland. Comorbidity may be an important factor.     

Shortening waiting lists in orthopaedic surgery outpatient clinics.

There is a long waiting list for orthopaedic outpatient appointments in South Glamorgan Area Health Authority as elsewhere. A detailed study of that waiting list was undertaken to identify factors that might lead to its better management and reduction. One-third of patients on the list failed to attend when appointments were offered. A postal-questionnaire to all those listed as waiting confirmed that many no longer sought specialist orthopaedic consultation. Another third of the patients reported that they had been treated previously for the same orthopaedic problem. It is concluded that improved management of long outpatient waiting lists could be achieved by correspondence with referring general practitioners to weed out those patients who no longer wish to attend, to reduce the burden of reviews and re-referrals of patients with "chronic" conditions, and to request priorities fairly so that earlier appointments may be offered to truly "new" patients with treatable or with potentially serious conditions.     

Waiting list for nursing home admission gives limited insight of the problems. Study in handling of the waiting list and the consequences for the patients

The waiting list for nursing home admission is expected to remain unacceptably long. A study of the use and of possibly problematic consequences of the waiting list was described in a thesis. Despite long mean waiting periods and many problems (depressive symptoms, experiences of burden) already at the start of the waiting period, the majority of the informal caregivers were satisfied with the waiting times. This may be explained by a reticence to nursing home admission and by enlistment to the waiting list "out of precaution". Both a long and a short waiting period could be experienced as too long. Waiting list figures give insufficient insight in the "real" demand for nursing home care and in problematic waiting periods.     

A quality improvement program to reduce the time on the lung transplant waiting list at the Nantes University Hospital

Background

In 2010, the time on the lung transplant waiting list in Nantes University Hospital (NUH) was 9.2 months, compared to a French national median of about 4 months. The NUH transplant unit performs both heart and lung transplantations, which can be seen as competing activities. To fix the problem, the adult Cystic Fibrosis (CF) team decided to engage in the French CF Quality Improvement Program (QIP PHARE-M) in 2012. The objectives were: i) To reduce the time on the lung transplant waiting list at the Nantes Transplant Unit by increasing the number of lung transplants per year twhile maintaining a 5-year survival rate above the French national average. ii) To improve the organization of the lung transplant access process and the quality of the waiting time for patients.

Methods

A quality controller was involved as the QIP referent to coach the CF quality team, analyze the pre-transplant process, and set up meaningful measures. Benchmarking was performed with other transplant units, and staff discussions were held with the Transplant Team (TT) to assess the outcomes of rejected donor lungs. Negotiations were made with the hospital administration. Plan, Do, Study and Act cycles were used to redesign the pre-transplant assessment in connection with the CF centers (CFC) referring patients to the NUH transplant unit.

Results

i) The flow of patients has been reorganized, decreasing the time spent in surgical intensive care by increasing the number of beds in the intensive care unit, and a chest physician has been recruited ii) The number of organs rejected has been reduced iii) Lung transplant activity has increased to 20–25 transplants per year, and the median waiting time was reduced to 3.5 months for patients transplanted in 2014 and to 1.85 months for patients transplanted in 2015 iv) Added-value activities including education, information, and psychosocial support are now offered to patients during the waiting time.

Conclusion

The QIP PHARE-M, including coaching by a quality-engineer, has helped our adult CF center address its specific lung transplant issues and redesign the lung transplant process for both local patients and patients referred by other CFC.

     

Waiting list for kidney transplant. Some patients wait too long.

The selection of a kidney graft recipient should be made not only taking into account biological and clinical parameters, for assuring the maximum possible clinical success; the ethical objective to allow every patient equal opportunity of receiving a transplant should also be pursued. In every waiting list of transplant candidates a proportion of patients remains in the list for a particularly long time. The present analysis aimed to find out the factors associated with a prolonged waiting time, in order to allow the implementation of patient selection criteria able to balance unfavourable factors. The analysis of the waiting list of our kidney transplant centre allowed to observe that blood group 0, anti-HLA immunisation, presence of rare HLA antigens and, at a lesser extent, HLA homozygosity are associated with a longer waiting time for a kidney transplant.     

Waiting times: monitoring the total postreferral wait.

OBJECTIVES--To determine whether the period spent on the true inpatient waiting list is a valid indication of the total time that patients have to wait for an operation; and to assess the feasibility of monitoring the total "postreferral waiting time" by using existing computerised information systems. SETTING--Three randomly selected Scottish hospitals. SUBJECTS--Waiting list patients admitted to hospital for operations during June to August 1993 in six major specialties, separate attention being focused on cataract operations and hip and knee replacements. MAIN OUTCOME MEASURE--The total time that patients have to wait for an operation after the initial general practitioner referral--the postreferral waiting time--compared with that spent at the final stage of the process on the true inpatient waiting list. RESULTS--In the specialties investigated roughly half (58 days; 53%) of the average postreferral wait of 110 days was spent on the true inpatient waiting list, one third (35 days; 32%) being spent on the outpatient waiting list and one sixth (17 days; 15%) waiting between waiting lists. Only a quarter of cataract patients (73/292) were treated within three months of general practitioner referral compared with over three quarters (228/292) within three months of being placed on the inpatient waiting list. Nevertheless, within a year over 99% of patients (290) had been treated whichever date was taken as the starting point. CONCLUSIONS--Monitoring postreferral waiting times would provide a much more accurate picture for purchasers and patients of waiting times for treatment than is obtained by focusing exclusively on the true inpatient waiting list and facilitate fairer comparisons between NHS trusts in national league tables. Stringent national and local monitoring is essential to ensure (a) that future reductions in the time waiting on true inpatient waiting lists are not gained at the expense of longer periods waiting to be placed on the lists, and (b) that no increases occur in the number of patients placed instead on deferred waiting lists or exempted from the normal maximum waiting time guarantees.     

Access to adult liver transplantation in Canada: a survey and ethical analysis.

OBJECTIVES: To describe the substantive and procedural criteria used for placing patients on the waiting list for liver transplantation and for allocating available livers to patients on the waiting list; to identify principal decision-makers and the main factors limiting liver transplantation in Canada; and to examine how closely cadaveric liver allocation resembles theoretic models of source allocation. DESIGN: Mailed survey. PARTICIPANTS: Medical directors of all seven Canadian adult liver transplantation centres, or their designates. Six of the questionnaires were completed. OUTCOME MEASURES: Relative importance of substantive and procedural criteria used to place patients in the waiting list for liver transplantation and to allocate available livers. Identification of principal decision-makers and main limiting factors to adult liver transplantation. RESULTS: Alcoholism, drug addiction, HIV positivity, primary liver cancer, noncompliance and hepatitis B were the most important criteria that had a negative influence on decisions to place patients on the waiting list for liver transplantation. Severity of disease and urgency were the most important criteria used for selecting patients on the waiting list for transplantation. Criteria that were inconsistent across the centres included social support (for deciding who is placed on the waiting list) and length of time on the waiting list (for deciding who is selected from the list). Although a variety of people were reported as being involved in these decisions, virtually all were reported to be health to be health care professionals. Thirty-seven patients died while waiting for liver transplantation in 1991; the scarcity of cadaveric livers was the main limiting factor. CONCLUSIONS: Criteria for resource allocation decisions regarding liver transplantation are generally consistent among the centres across Canada, although some important inconsistencies remain. Because patients die while on the waiting list and because the primary limiting factor is organ supply, increased organ acquisition efforts are needed.     

Mortality in elderly patients admitted for respite care.

OBJECTIVE--To determine whether admitting elderly patients to hospital to give temporary relief to their carers is associated with increased mortality. DESIGN--Prospective multicentre study comparing the mortality of patients admitted on a one off or rotational basis with that experienced while they were awaiting admission. SETTING--A wide range of urban and rural district general, geriatric or long stay, and general practitioner hospitals. PATIENTS--474 Patients aged 70 or over who had 601 admissions. MAIN OUTCOME MEASURE--Death. RESULTS--16 (3.4%) Of the 474 patients (2.7% of all 601 admissions) died while in hospital during an average stay of 15.7 days whereas 23 (4.9%) patients died while awaiting admission (average waiting time was 34.2 days). The 16 deaths in hospital and the 23 deaths during the longer waiting period correspond to death rates of 19.9 and 12.5 per 10,000 person days respectively. The difference between these of 7.4 is not statistically significant (95% confidence interval -3.6 to 18.3). The estimated relative risk of dying in hospital is 1.59 but the 95% confidence interval is wide (0.84 to 3.01). CONCLUSION--Although the death rates are slightly higher in those admitted to hospital for relief care than in those awaiting admission, the difference was not significant, and the death rate in both groups was reassuringly small.     

Estimating list inflation in a practice register.

The reason why patients were incorrectly registered in an age-sex register was studied. Whereas underregistration was caused by patient delay in registering with a doctor, the much greater number of overregistered patients were thought to be there largely because of administrative delays in removing their names from the register. It is suggested that it would be possible for the software of a computer system in general practice to correct the population size and structure for estimated list inflation.     

Spousal agreement on preferred waiting time to next birth in sub-Saharan Africa

This study investigates how various social, demographic and economic factors affect spousal agreement on preferred waiting time to next birth. Data for matched cohabiting couples from ten Demographic and Health Surveys in sub-Saharan Africa (Benin, Burkina Faso, Ghana, Guinea, Mali, Ethiopia, Kenya, Mozambique, Zambia and Zimbabwe), conducted between 2003 and 2006, were analysed to compare reported waiting time to next birth by the husband and the wife. Couples where the reported waiting time to next birth was the same for both partners (difference is 0 months) were defined as having agreement on waiting time to next birth. In sub-Saharan Africa, spousal agreement on waiting time to next birth was found to be associated with wanting the next child sooner. When the spouses disagree on waiting time to next birth, the wives want to wait longer than their husbands in most cases. Additionally, the study found that demographic factors are the primary determinants of spousal agreement on waiting time to next birth, not socioeconomic factors. The strongest predictors of spousal agreement on waiting time to next birth were number of living children, difference between the number of ideal and living children and wife's age. Couples with fewer children, a younger wife and those with a difference of five or more children between ideal and living number of children were more likely to agree on waiting time to next birth. Effects of socioeconomic factors, such as education and wealth status, on spousal agreement on waiting time to next birth were generally weak and inconsistent. The findings highlight some of the challenges in developing programmes to promote spousal communication and birth spacing and underscore the need for programmes to be gender-sensitive.     

Long-Stay Patients in Canadian Mental Hospitals, 1955-1963

Changes in the number and characteristics of patients in Canadian mental hospitals during 1955-1963 were studied in order to assess the future need for long-term hospital care.Despite marked increases in the number of first admissions and readmissions, the average number of patients in hospital decreased 6% from 49,537 in 1955 to 46,498 in 1963.Patients who were “long stay” in 1955 continued to leave hospital at the same rate during the years 1960-1963 as during 1955-1959. No “hard core” of long-stay patients with reduced potential for discharge seemed to have formed by 1963.Since 1955 the number of “admissions” remaining continuously hospitalized has progressively decreased for the elderly and for patients with psychoses. No build-up of new long-stay patients from patients with repeated short admissions was evident.The estimate of the Royal Commission on Health Services that the ratio of patients in mental hospitals could be reduced from 3.0 per 1000 in 1961 to 1.5 per 1000 by 1971 seems feasible.     

Intentional iron overdose: an institutional review.

OBJECTIVE: To document the frequency of admissions and the outcome of patients with a diagnosis of intentional iron overdose to a large urban hospital. DESIGN: Retrospective review of hospital records. SETTING: Health Sciences Centre, Winnipeg, an 1100-bed primary and tertiary care centre serving a regional population of about 1.2 million. PATIENTS: All patients with a discharge diagnosis of iron overdose who were admitted from Jan. 1, 1979, to July 1, 1991. Of these 113 cases 66 (58%) represented an intentional iron overdose on the basis of information derived from the patient, family or friends. MAIN OUTCOME MEASURES: Frequency of admissions, length of hospital stay and survival rate. RESULTS: Most (53 [80%]) of the 66 patients were females. The mean age was 19.8 (standard deviation [SD] 6.1) years (range 9 to 48 years). One third of the cases were associated with excess alcohol intake. The frequency of hospital admissions increased during the study period (1.4 cases per year in the first 5 years and 9.8 cases per year in the last 5; 5.3 cases per year overall). The mean length of hospital stay was 6.8 (SD 12.1) days, and the mortality rate was 10%. CONCLUSIONS: Hospital admissions because of intentional iron overdose are becoming more frequent in this centre and are associated with appreciable morbidity and mortality rates. Prospective studies are required to delineate clearly the signs, symptoms and abnormal laboratory findings associated with this problem.     

Long distance travel for routine elective surgery: questionnaire survey of patients' attitudes.

OBJECTIVE--To carry out an audit and assess the acceptability of long distance travel to patients on a lengthy surgical waiting list. DESIGN--Audit and questionnaire survey. SETTING--Military hospital in Wiltshire. PATIENTS--116 Patients on a general surgical waiting list at Leighton Hospital near Crewe. INTERVENTIONS--Preselection for medical fitness at a waiting list review clinic. RESULTS--Roughly half of patients offered the facility of travelling 120 miles (190 km) for their routine elective operation at the health authority''s expense accepted. The average waiting list time declared by the patients who travelled was 28 months, and 13 patients stated that their condition prevented them from working. Only four patients regretted their decision to participate in the scheme. Lack of visitors did not cause undue concern. CONCLUSIONS--Some patients did not agree to travel for their operation but almost all of those who did so found the scheme satisfactory. Some minor problems were encountered but these could probably be overcome by ensuring use of appropriate transport, extending the postoperative stay when necessary, and more careful selection of patients for an anaesthetic. For efficient use of theatre time in such schemes it is crucial that the operating consultant surgeon should be in charge of case selection.     

Trends in the hospital care of acute childhood asthma 1970-8: a regional study.

In the South-west Thames Region over the period 1970-8 the number of admissions for asthma in children aged 5-14 years increased from 256 to 684, an increase of 167%. Factors associated with this trend were investigated by an analysis of routine hospital statistics and examination of case notes for 1970 and 1978 from every hospital in the region. The trend was caused partly by an increase in readmission rates. There was a more than fivefold increase in self-referrals; these patients had less severe asthma on admission and a higher readmission rate than patients referred by general practitioners. Drug management before and after admission changed considerably over the nine years, as did hospital investigations. Overall, there was little change in the level of severity on admission. The increase in admissions was not associated with a reduction in deaths from asthma in the region and occurred in spite of major advances in the drug control of asthma; this indicates an inadequacy of ambulatory care. The shift in the balance of care towards the hospital and the increasing adoption of a primary care function by the hospital indicate a need for hospitals and general practice to agree jointly on management policies for acute asthma.     

An evaluation of home visiting of patients by physicians in geriatric medicine

The practice of preadmission home visiting of patients referred to geriatric medicine units has in recent years been criticised as being unnecessary on the grounds that if there is no waiting list there is no need for allocation of priority for admission; as being wasteful of doctors'' time; as being resented by general practitioners; and as failing to provide adequate clinical information. The geriatric medicine department at the City Hospital with no waiting list for patients referred by general practitioners has retained home visits for most referrals because of the advantages in terms of acceptability to general practitioners (98-100%); the quantity and quality of information obtained; the usefulness of this information in deciding appropriate management and in planning discharge from hospital; and the provision of a unique teaching opportunity, which is highly valued by students and teachers alike.     

Fracture of neck of the femur: changing incidence.

From 1959 to 1977 the numbers of hospital admissions for fracture of the neck of the femur increased by a factor of 2.7. Detailed analysis of data from the Hospital In-Patient Enquiry for 1968-77 showed that the increase applied to both sexes and at all ages over 45. The true incidence rate increased in parallel with the admission rate, and only a small part of the increased number of admissions was explained by the increasing numbers of the elderly. The increasing incidence of fracture of the neck of the femur imposes great strain on hospital resources, particularly trauma and orthopaedic departments, and merits urgent investigation. An explanation for the increase might be that the experience of one demand-led condition characterises a greater need for health care among the elderly for other conditions.     

Unemployment rate as predictor of rate of psychiatric admission.

OBJECTIVE--To examine the relation between rates of psychiatric admissions and both the rate of unemployment and the underprivileged area score within small areas. DESIGN--Calculation of correlation coefficients and explanatory power by using data on psychiatric admissions from April 1990 to March 1992. Crude and age standardised rates were used based on all admissions and also on the number of people admitted regardless of the number of times each person was admitted. SETTING--Sectors with an average population of 45,000 consisting of aggregations of neighbouring wards in Bristol and District Health Authority and electoral wards with an average population of 9400 in the city of Bristol. RESULTS--Unemployment rates explained 93% of the variation in the crude person based admission rates standardised for age for those aged under 65 in the sectors. Person based rates correlated more strongly with unemployment than did rates based on all separate admissions. Inclusion of people aged 65 and over weakened the relation. Within electoral wards unemployment rates explained only about 50-60% of the variation but were still more powerful than the underprivileged area score. There was a significant negative correlation between average length of stay and readmission rates--that is, sectors with short lengths of stay were more likely to have patients readmitted (r = -0.64, 95% confidence interval -0.25 to -0.85). CONCLUSIONS--Unemployment rates are an extremely powerful indicator of the rates of serious mental illness that will need treatment in hospital in those aged under 65. This should be considered in the process of resource allocation, particularly to fundholders in general practice, or people with serious mental illness living in areas of high unemployment could be considerably disadvantaged.