Preoperative surgical scoring systems

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Pre-operative surgical scoring systems waiting
lists
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Prioritisation methods in Gynaecology - old and
new
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Why?
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Clinical need
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Traditional Method of Providing Publicly Funded
Health Services
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2005 Hysterectomy and T/L rates

• Standardised ratios for each DHB
• Takes into account age, ethnicity, social issues

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Level of publicly funded hysterectomy procedures
2005
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National
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Tubal Ligation
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National
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• Fundamental Principles for Access to Publicly
  Funded Elective Services
• Clarity
• Timeliness
• Fairness

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Statement on Safe Practice in an Environment of
Resource Limitation

• Dealing with outpatients
• A service has a duty to ensure that only those
  referrals that can be seen within the resources
  available (including time, staffing and physical
  resources) are accepted.
• As far as possible assessment should fairly
  establish the patients priority for treatment
  compared to that of other patients. For example,
  a doctor working in both public and private
  practice should only be able to shift patients
  from his or her private practice to the public
  system if those patients are subject to the same
  priority assessment criteria and are not seen
  before more needy patients in the public booking
  system.
• Doctors have a responsibility to ensure that the
  process of assigning priority is appropriate.

Approved by Council October 2005
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Statement on Safe Practice in an Environment of
Resource Limitation

• Dealing with outpatients
• A service has a duty to ensure that only those
  referrals that can be seen within the resources
  available (including time, staffing and physical
  resources) are accepted.
• As far as possible assessment should fairly
  establish the patients priority for treatment
  compared to that of other patients. For example,
  a doctor working in both public and private
  practice should only be able to shift patients
  from his or her private practice to the public
  system if those patients are subject to the same
  priority assessment criteria and are not seen
  before more needy patients in the public booking
  system.
• Doctors have a responsibility to ensure that the
  process of assigning priority is appropriate.
  Referrals to a service with limited resources
  should be seen in order of priority and a patient
  should receive treatment in accordance with his
  or her assigned priority. Prioritisation systems
  should be fair, systematic, consistent,
  evidence-based and transparent.

Approved by Council October 2005
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Patient pathway electives
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Patient pathway electives
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Clinical Priority Access Criteria (CPAC)

• Points systems are widely-used internationally
  for combining patients characteristics on
  multiple criteria
• Simple to use
• More accurate than the unaided expert judgments
  of decision makers.

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The Gynae CPACs

• General Gynaecology
• Sterilisation
• Assisted Reproduction

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The Gynae CPACs

• General Gynaecology
• Sterilisation
• Assisted Reproduction

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Why has the ART CPAC worked?

• Valid (Objective) Criteria
• Reflecting clinical need and ability to benefit
• Clinician Compliance

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Problems with Gynae CPAC

• One tool had to accommodate diverse conditions
  from cancer to prolapse
• Weighted heavily towards cancer and precancer
• Weighted slightly towards pain conditions

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Problems with Gynae CPAC

• Weighted against
• Menorrhagia
• Prolapse
• Incontinence

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Problems with Gynae CPAC

• Poor reliability
• Changes made
• Increasing thresholds made it unworkable
• Difficulty with differentiation
• Loss of confidence
• Inconsistent national application and use

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Inconsistent use
Tubal ligation
Hysterectomy
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RANZCOG Elective Services Working Group
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Wayne Gillett Dunedin Deryck
Pilkington Rotorua Keith Allenby Middlemore Ian
Page Whangarei Michael East Christchurch Di
Poad Christchurch Lorraine Welch Hutt Al
Haslam Hamilton Sarah Tout Dunedin
OG Specialists
Ministry of Health Alison Barber Ray Naden Clare
Perry
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Scope Redefined

• Cancer and pre-cancer removed
• Infertility removed

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18 Cases (Vignettes)

• Reflecting the range of conditions and severity

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Case A

• 43 year old
• Menorrhagia
• Estimated gt 80 ml
• Hb 100 g/L
• Ultrasound normal uterus
• Impact - activities compromised 3-4 days
• Previous bad experience with IUCD
• Failed medical Rx

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Case B

• 43 year old
• Menorrhagia Dysmenorrhoea
• Estimated gt 80 ml
• Hb 100 g/L
• Ultrasound normal uterus
• Impact - avoids some activities 3-4 days
• Previous bad experience with IUCD
• Failed medical Rx

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Case D

• 43 year old
• Menorrhagia
• Estimated gt 80 ml
• Hb 100 g/L
• Ultrasound normal uterus
• Impact - activities compromised 3-4 days
• Previous bad experience with IUCD
• Failed medical Rx
• BMI 45

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A
B
D
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General Gynaecology CPAC Clinical Ranking
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Vignettes Ranked by Best Practice Standard
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Priority Criteria

• What criteria should be used to determine
  priority for access?
• Clinical need
• Severity and extent of disease
• Impact of condition on life
• Ability to benefit
• Likelihood and duration of optimal outcome
• Degree which impact is reversible

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Three criteria

• Impact on life
• Effectiveness of procedure
• Risk of complications /adverse effects

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Effectiveness of procedures in improving impact
on life

• lt50 likelihood of optimal outcome
  (Substantially limited)
• 50-80 (Significantly limited)
• 80-95 (Somewhat limited)
• gt95 (High)

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Assessment of effectiveness

• Should be based on the usual effectiveness of
  that procedure
• Assessing anything of relevance to the particular
  patient that would increase or reduce that
  effectiveness.
• It needs to reflect evidence-based practice that
  may come from local, national or international
  sources

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Risk of complications / adverse effect of the
surgical procedure

• Substantially increased 1 5 risk of major
  morbidity or mortality (e.g. MI last 6 months)
• Mildly increased (e.g. PHx DVT/PE)
• Not increased above normal

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Impact on life - step 1

• Determine how the predominant symptom is
  affecting the woman in her ability to participate
  in, or perform, activities important for her

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Impact on life

• No significant compromise
• No significant compromise because controlled by
  non-surgical options
• Important aspects are compromised
• Made more difficult
• Reduced or postponed
• Important activities are avoided
• Avoidance of or inability to engage in sexual,
  sport,social, work or home activities

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Impact on life - step 2

• Determine the duration of the impact
• For at least 2 days
• For at least 7 days
• For whole of month

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Point Wizard

• Internet-based software for creating a valid and
  user-friendly tool for prioritising patients for
  elective surgery

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Impact on life

• No compromise in any important activities
• Avoids some important activities for the whole of
  the month

0
68.8
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Vignettes Ranked by Best Practice Standard
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CPAC Validity
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• A woman who has heavy painful periods for 4 days
• feels tired and drained for this time
• but is mostly able to participate in activity

has compromise for at least 2 days
54
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• A woman who has heavy painful periods for 4 days
• feels tired and drained for this time
• and cannot go to work for at least 3 days

avoids activities for at least 2 days
67
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• A woman who has heavy painful periods for 4 days
• feels tired and drained for this time
• and cannot go to work for at least 3 days
• but is more troubled by dyspareunia for which
  intercourse has reduced frequency, is made more
  difficult because of the pain

Is compromised for the whole month
77
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• A woman who has heavy painful periods for 4 days
• feels tired and drained for this time
• and cannot go to work for at least 3 days
• is more troubled by dyspareunia for which
  intercourse is impossible/avoided because of the
  pain

Avoids activities for the whole month
100
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Pilot Testing

• Purpose
• To test clinical usability and acceptability
• Test whether proposed CPAC improves
  prioritisation consistency
• Test correlation with treatment decisions

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Interpretation Notes

• The focus is to reflect on the impact of the
  symptoms on life rather than to specify the
  nature and degree of symptoms. In evaluating two
  separate symptoms, the symptom with the highest
  weighting should be taken.
•  
• There are 3 steps to assigning a category
•  
• i)   Determine how the predominant symptom is
  affecting the woman in her ability to participate
  in, or perform, activities important for her.
•          No significant compromise symptom does
  not significantly affect the womans ability to
  participate in any activity important to her
•          No significant compromise because the
  symptoms are controlled with non surgical
  management e.g. use of pads for incontinence or
  medication for pain management
•          Important activities are compromised in
  spite of non-surgical management eg. made more
  difficult/embarrassing or reduced or postponed
•          Important activities are avoided or
  prevented eg. avoidance of or inability to engage
  in sexual, sport, social, work and home
  activities.
•  
• ii) Determine the duration of the impact on life
  using the separate categories (Avoids or
  Compromises activities for at least 2 days, at
  least 7 days or for the whole of the month)
•  
• iii) Assign one of eight categories.

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