Hypothesis / aims of study
Pooled surgical waiting lists have been suggested as a strategy to improve use of surgical resources. In a pooled surgical wait list system, the patient is assigned to the next available surgical time even if it is not with the consultant by whom they were initially assessed. This pooling allows for more even distribution of workload between surgeons and more uniform surgical wait times. Pooled surgical wait lists may also allow for exchange of surgeon responsibilities for ease of scheduling and may allow for optimal use of surgical time since shorter cases from the pool can be used to fill any remaining surgical time. Pooled-surgical wait lists have been described in ophthalmology and orthopedic literature and are currently used in many oncologic surgery specialties. There is no literature regarding patient acceptance of pooled wait lists in gynecologic, urologic or urogynecologic populations. We sought to determine patient acceptance of a pooled surgical waiting list for urogynaecology and pelvic reconstructive surgical procedures. We hypothesized that patients would be accepting of having their surgery done by the next available skilled surgeon on a pooled wait list rather than wait for their own provider.
Study design, materials and methods
Patient and provider focus groups were used to inform survey design and the survey was piloted for readability. Patients were invited to complete the anonymous survey if they had signed consent for pelvic floor surgery between February 2018 and December 2018 with one of 5 urogynecologists at a tertiary care centre. Women who were unable to independently complete the paper consent or unable to read in English or in French were excluded. Only completed surveys were used for analysis. Surveys were completed immediately after consenting for prolapse or urinary incontinence surgery.
The primary outcome of interest was patient acceptance of pooled surgical wait lists in terms of agreement on a five-point Likert scale with the statement “I would like the option of having my surgery done by the next available skilled surgeon, rather than wait for my own surgeon”. Secondary outcomes included the importance of other factors relevant to a pooled surgical wait list (such as perception regarding complications, acceptable wait time and connection with the surgeon).
We aimed for a sample size of 176 patients to achieve a confidence interval of 90% with a 5% margin of error. Categorical variables are reported as number (%) and were compared via chi squared tests. Pre-specified stratified analyses were completed comparing women 65 years or over to those under age 65, comparing women having mid-urethral slings alone versus those having other procedures and comparing women with self-perceived “severe” condition versus those with mild/moderate or normal condition severity (based on survey response). All analyses were performed using Stata 15.1. A two-tailed α level of 0.05 was used to define statistical significance.
One hundred and seventy-six (176) patients completed the survey out of 215 women approached (81%). Most women (83.4%) were ≥45 years old. The most common surgeries for which women signed consent were vaginal hysterectomy, prolapse repair, mid-urethral sling, or a combination of these procedures (90.1%). Most women (44.9%) described the severity of their condition as moderate and 37.5% of women felt that their condition was severe. Only 19% (33/176) of patients overall “agreed/ strongly agreed” that they would like the option of choosing a pooled surgical wait list. Only 18% (32/176) would agree to be on a pooled waiting list for surgery if they knew the wait time was shorter. Over half of those surveyed (54.3%) felt that a reasonable wait time for surgery was 6-12 months.
Women 65 years or older were more likely to disagree/strongly disagree that they would like the option of a pooled surgical wait list (56.2% vs 72.0%, p=0.028). There was no difference in acceptance of pooling by perceived condition severity. 61% of women who perceived their condition as severe disagreed/ strongly disagreed that they would like the option of a pooled surgical wait list (p=0.064, vs 67% for women with perceived mild/moderate condition severity). There was no difference in acceptance by women having mid-urethral slings alone with 65.9% disagreeing/ strongly disagreeing that they would like the option of a pooled surgical wait list (vs 65.1% of those having combined or other procedures, p 0.26). 70.5% of respondents agreed/strongly agreed with the statement: “regardless of their skill, it is important for me to feel a connection with my surgeon” and 74.0% of respondents agreed/strongly agreed that they would “feel more upset about a surgical complication if it occurred with a surgeon that [they] had met only once before surgery”.
Interpretation of results
Patients having pelvic reconstructive surgery have a lower acceptance of pooled surgical wait lists than patients in other surgical sub-specialties such as ophthalmology and orthopedics (1, 2). These differences may be related to patient demographics or chronic nature of the diagnoses. Patients with chronic health conditions appear to be willing to accept longer wait times in order to be cared for by a physician with who they have already established a relationship (3).
Patient perception regarding importance of continuity of care with pelvic floor conditions may also play a role since surgical goals may be based on an understanding of patient priorities such as maintenance of sexual function. Patients' opinions regarding a pooled wait list model will help to guide strategies for wait time reduction and strategies for optimization of patient flow.