Waiting for the knife – orthopaedic surgery in the time of COVID-19

Bibhas Roy and James Wilson

Bibhas Roy is a Consultant Orthopaedic Surgeon, Manchester University Foundation Trust.

James Wilson is an Upper Limb Consultant Surgeon from Bolton.

Healthcare has long recognised that rules are necessary to distribute medical resources equitably in situations of scarcity[1]. Various models are described, all require ‘triage’ in some way. This inevitably creates ethical questions and requires specific policies.

Waiting for care is a characteristic of many health systems; more so in publicly funded ones[2]. It is also clear that waiting times statistics exist mainly in countries with tax-financed health systems, rather than countries with health systems funded through contributions[3].

The COVID-19 pandemic has affected and sometimes overwhelmed healthcare infrastructure and resources[4] requiring concepts of ‘triage’ to be introduced.

Originating from the French verb ‘trier’ meaning ‘to sort’, triage has been used in healthcare primarily in ‘mass casualty’ incidents. Although used extensively in the military[5], the concepts are also used in emergency departments[6]. Effective triage is a specific skill, and authors have noted that ‘most who write scholarly articles on the subject have never practiced triage, or even witnessed it!’[5]. It is also important to recognise that demands can create the need to ration medical equipment and interventions[7], making concepts of resource allocation necessary for a complete solution.

The three components of triage are sorting, prioritising and allocating resources[8] Sorting requires assigning a ranked value or priority to what is being sorted, which inevitably creates a prioritisation hierarchy. Resource allocation becomes necessary as the magnitude of the problem increases to an ‘overwhelming’ level, highlighting the concept of ‘the greatest good for the greatest number’ and implying a shift in decision making from a focus on individual patient outcomes to population-level outcomes. These concepts are not new, with theories of utility described first in the 1700s, along with other philosophical principles such as the difference principles of justice, principle of equal chance etc.[9].

In addition, triage does not necessarily conform to modern ‘values’ of medicine such as autonomy – the right of the patient to choose treatment via informed consent and fidelity – the clinician is not always able to act on the best interest of individual patients, etc. A system that allocates the benefits of healthcare aswell as the burden of limited or deferred care within the population is created.

Elective orthopaedic surgery

Systems to prioritise elective surgical patients[10] and their validation have been discussed for many years[11]. These have addressed the entire patient pathway including the referral, the clinical symptom load, and the management of waiting lists[2,10,12]. In the setting of COVID-19, elective orthopaedic surgery has suffered particularly as the problem is perceived to be less important than other clinical scenarios such as cancer care[13].

Waiting is a key characteristic of the NHS and in the UK over 100,000 patients are waiting for joint replacement surgeries[13]. Unlike many aspects of the quality of care, waiting is relatively easy to measure and hence has received much attention [14]. Complex waiting list clinical prioritisation models in the NHS have not been adopted, and the simplistic first in first out (FIFO) model is used widely.

While FIFO is simple to use and can be a good tool to model healthcare demand, it uses arbitrary thresholds (i.e. 18 weeks) to prioritise lists. Combining waiting times with clinical variables to create better queuing systems have also been explored.

COVID-19 response

At all institutional/governmental levels the COVID-19 pandemic response has considered systems adhering to the above principles. Systems were optimised to care for COVID-19 patients with cancellation rates between 71.2– 87.4% for elective non-cancer surgery during the initial 12-week period following March 2020[15]. Worldwide, possibly over 115 million operations have been cancelled[16]. Elective surgery has now restarted in most areas, and policies are in operation to process the procedures safely. There are examples where active surveillance of resource availability and case urgency have been taken into account to develop comprehensive policies[17].

NHS surgical priority groups

The Federation of Surgical Specialty Associations (FSSA) Guide was first produced at the request of NHS England at the start of the pandemic. The Guide states that “it is a short-term expedient to the pandemic and not for long term use” and it follows the prioritisation systems (P1-4) used in emergency departments[5]. Evaluating the potential benefit of a treatment to a patient, involves determining the incremental benefit of that treatment compared with receiving a less resource-intensive or delayed treatment, but rarely does this mean no treatment. It is now recognised that the FSSA prioritisation system, especially the P3/P4 categories, is not valid for T&O but it does map to more familiar clinical systems (Table 1).

We acknowledge that waiting time is an important metric, RTT is measured routinely in the NHS, and should not be abandoned. Without RTT management, it is possible that a patient will never reach the front of the queue.

If the FSSA categories are ‘abandoned’ a more discrete five-stage process could be developed. Appendix 1 illustrates a suggested process of managing an orthopaedic waiting list incorporating the FSSA P1-4, P5 and P6 categories into ones that are more familiar and have been used historically, so the ‘routine’ patients are managed more effectively.

However, we believe a composite system that considers both waiting time as well as clinical prioritisation elements is a better system to deliver elective services that are effective and equitable. We propose a modified RTT system, which takes into account, variables such as, demographics, clinical state (PROMs), state of deprivation etc. The modifiers added according to local agreements with weighting of these variables yet to be determined. Examples are provided in Appendix 2.

References

References can be found online at: www.boa.ac.uk/publications/JTO.

Appendix 1 - SOP waiting list management

Step one: Clinical prioritisation at the time of listing for surgery.

Step two: A technical validation of the waiting List data for current accuracy/completeness.

Step three: Contacting the patient to explain what is happening. They should receive indication of the likely waiting time, how the categorisation works and which category they are in. They should be given contact details for questions or if their symptoms change. (Template letters are available from NHS England. See link below.) Patients may express the wish to be taken off the waiting List (TOWL), to postpone their surgery due to COVID-19 concerns (P5) or non-COVID-19 concerns (P6). They may also request a consultation to discuss things further.

Step four: Remote or face-to-face consultation with appropriate up-to-date imaging conducted in a COVID-secure manner. The patient/clinician explore the implications of proceeding with surgery versus delaying or pursuing alternative treatments. The discussion should follow the principles of shared decision making. Again the outcomes are, remaining on the waiting list, P5, P6 or TOWL, which should be confirmed in writing to the patient and their GP. The patient remains free to change their mind but after 28 days, a GP re-referral would be required for a TOWL outcome.

Step Five: Planned review of patients waiting a long time for surgery including P5/ P6 cases. The review should consider whether the treatment type or complexity has changed. Discussion should include the impact of COVID-19 and the delay in treatment in terms of patient de-conditioning and options to mitigate this. It should also examine whether there is a need to alter the priority level. We recommend this is performed at least every six months[3].

The BOA recommends that these consultations are scheduled and resourced with allocated appointments. The time taken to perform and document these reviews should be included in job planning.

• NHS England template letters for patient communication www.england.nhs.uk/ coronavirus/publication/validating-waiting-lists-framework/?preview=true.

• BOA and Specialist Society Position paper on caring for patients awaiting surgery www.boa.ac.uk/uploads/assets/cbe0c0ed-40c3-405f-a5daffe7f8c2f350/BOA-specsoc-prioritisation-patient-reviews-FINAL-v11.pdf.

• Scottish Government - Coronavirus (COVID-19): supporting elective care - clinical prioritisation framework www.gov.scot/publications/supporting-elective-care-clinical-prioritisation-framework/ pages/principles.

Appendix 2 - Modified RTT - modelling modifiers to enhance RTT usability

The Referral to Treatment Time (RTT) measure is well established as a means of monitoring and incentivising trusts to manage their waiting lists. Additional information can be combined with this one metric to improve this basic queuing model for a Modified RTT (MRTT). This assessment of priority could continue to be measured in terms of weeks. Keeping the same units that we already use to retain a degree of realism and ease of interpretation.

Age modifier for RTT

To illustrate this concept, we have fabricated a section of a waiting list and look at age as an additional factor in prioritisation. In general, older patients would have fewer years left to gain benefit from an intervention. Therefore trying to reduce the number of months or years on a waiting list with diminishing health is a reasonable justification to prioritise these cases.

One way to effect this modification would be to calculate the number of years over 70 the patient is and increase the RTT by this. As Patient E is 82 (12+70) he would get his RTT increased by 12%. Other models i.e., choosing a different age to start modifying the RTT or greater weightings, or a non-linear adjustment could all be considered to alter exactly how an age-modifier might perform.

PROM modifier for RTT

Validated and standardised tools such as patient reported outcome measures (PROMs) are routinely collected pre- and post-operatively, for the NJR. They are designed to summarise and quantify symptom burden and impact on a patients’ life. The average pre-op OKS for patients awaiting primary knee replacement surgery is from 17-19 in large UK datasets[18]. Using this data, one could choose a value to allocate an additional priority weighting. For example, if the OKS were below 17 then the RTT could be increased by an extra 2% per point. Again, other thresholds, weightings or non-linear adjustments could be used.

The OKS is useful to help assess patients awaiting primary TKR and could be used for other knee pathologies although comparing across different conditions might require a generic quality of life PROM such as the EQ5D. Other patient demographics such as living alone, may also justify increasing their prioritisation such as living alone. A blanket modifier could be applied for this category e.g. RTT + 10%.

As with any data manipulation exercise assumptions are made which are open to criticism. The chronological age of an individual does not necessarily govern their frailty or life expectancy, using specific PROMs for a group of patients with the same diagnosis may be useful but where a waiting list includes a diverse set of diagnoses then this would not be appropriate. Using the generic health status score assumes that the reduced EQ5D is due to the problem they are listed for and that all orthopaedic problems have similar reductions in EQ5D for their severity.

The intention would not be to produce an algorithm to replace clinical decision or assessment but to provide some relevant data in a structured fashion to help support the process of managing our swollen waiting lists.