Hostname: page-component-84b7d79bbc-c654p Total loading time: 0 Render date: 2024-07-28T08:42:42.717Z Has data issue: false hasContentIssue false
  • English
  • Français

Priority Setting in Neurosurgery as Exemplified by an Everyday Challenge

Published online by Cambridge University Press:  23 September 2014

George M. Ibrahim ,
Michael Tymianski  and
Mark Bernstein
George M. Ibrahim
Affiliation:
Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada Department of Surgery, Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
Michael Tymianski
Affiliation:
Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada Department of Surgery, Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada Department of Physiology, University of Toronto, Toronto, Ontario, Canada Toronto Western Hospital Research Institute, University of Toronto, Toronto, Ontario, Canada
Mark Bernstein*
Affiliation:
Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
*
Toronto Western Hospital, 399 Bathurst Ave, Toronto, Ontario, M5T 2S8, Canada. Email: mark.bernstein@uhn.ca
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Background:

The allocation of limited healthcare resources poses a constant challenge for clinicians. One everyday example is the prioritization of elective neurosurgical operating room (OR) time in circumstances where cancellations may be encountered. The bioethical framework, Accountability for Reasonableness (A4R) may inform such decisions by establishing conditions that should be met for ethically-justifiable priority setting.

Objective:

Here, we describe our experience in implementing A4R to guide decisions regarding elective OR prioritization.

Methods:

The four primary expectations of the A4R process are: (1) relevance, namely achieved by support for the process and criteria for decisions amongst all stakeholders; (2) publicity, satisfied by the effective communication of the results of the deliberation; (3) challengeability through a fair appeals process; and (4) Oversight of the process to ensure that opportunities for its improvement are available.

Results:

A4R may be applied to inform OR time prioritization, with benefits to patients, surgeons and the institution itself. We discuss various case-, patient-, and surgeon-related factors that may be incorporated into the decision-making process. Furthermore, we explore challenges encountered in the implementation of this process, including the need for timely neurosurgical decision-making and the presence of hospital-based power imbalances.

Conclusion:

The authors recommend the implementation of a fair, deliberative process to inform priority setting in neurosurgery, as demonstrated by the application of the A4R framework to allocate limited OR time.

Résumé:

Résumé:Contexte:

L'allocation de ressources limitées en matière de soins de santé constitue un défi constant pour les cliniciens. Un exemple quotidien en est la priorisation du temps opératoire pour les cas électifs en neurochirurgie, dans des circonstances où des annulations peuvent survenir. Le cadre bioéthique, la responsabilité pour la raisonabilité (A4R), peut éclairer de telles décisions en établissant les conditions qui devraient être remplies pour une priorisation éthiquement justifiable.

Objectif:

Nous décrivons notre expérience de l'application de l'A4R pour guider les décisions concernant la priorisation du temps opératoire en neurochirurgie élective.

Méthode:

Les quatre principales attentes du processus A4R sont les suivantes: 1) la pertinence, établie notamment par le soutien pour le processus et les critères de décision de la part de toutes les parties prenantes ; 2) la publicité, réalisée par la communication efficace des résultats de la délibération ; 3) la possibilité d'appel par un processus équitable ; 4) la surveillance du processus afin de s'assurer de saisir les occasions de l'améliorer.

Résultats:

L'A4R peut être appliquée pour clarifier la priorisation du temps opératoire, ce qui bénéficie aux patients, aux chirurgiens et à l'institution elle-même. Nous discutons de différents facteurs relatifs aux cas, aux patients et aux chirurgiens qui peuvent être incorporés dans le processus décisionnel. De plus, nous explorons les défis rencontrés dans l'implantation de ce processus, dont le besoin de prendre des décisions neurochirurgicales en temps opportun et la présence de déséquilibre de pouvoir au sein du milieu hospitalier.

Conclusion:

Les auteurs recommandent l'implantation d'un processus de délibération juste pour clarifier la priorisation en neurochirurgie, comme nous l'avons démontré par l'application du cadre A4R pour l'allocation de temps opératoire limité en neurochirurgie.

Type
Research Article
Information
Canadian Journal of Neurological Sciences , Volume 40 , Issue 3 , May 2013 , pp. 378 - 383
Copyright
Copyright © The Canadian Journal of Neurological 2013

References

1. Beveridge, R, Ducharme, J, Janes, L, Beaulieu, S, Walter, S. Reliability of the Canadian Emergency Department triage and acuity scale: interrater agreement. Ann Emerg Med. 1999;34(2):155–9.Google Scholar
2. Baker, SP, O’Neill, B, Haddon, W Jr, Long, WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14(3):187–96.CrossRefGoogle ScholarPubMed
3. Bell, JA, Hyland, S, DePellegrin, T, Upshur, RE, Bernstein, M, Martin, DK. SARS and hospital priority setting: a qualitative case study and evaluation. BMC Health Serv Res. 2004;4(1):36.CrossRefGoogle ScholarPubMed
4. Daniels, N, Sabin, J. The ethics of accountability in managed care reform. Health Aff (Millwood). 1998;17(5):50–64.CrossRefGoogle ScholarPubMed
5. Daniels, N, Sabin, J. Setting limits fairly: can we learn to share scarce resources? Oxford: Oxford University Press; 2002.Google Scholar
6. Chiu, CH, Lee, A, Chui, PT. Cancellation of elective operations on the day of intended surgery in a Hong Kong hospital: point prevalence and reasons. Hong Kong Med J. 2012;18(1):5–10.Google Scholar
7. Mesmar, M, Shatnawi, NJ, Faori, I, Khader, YS. Reasons for cancellation of elective operations at a major teaching referral hospital in Jordan. East Mediterr Health J. 2011;17(8):651–5.Google Scholar
8. Lau, HK, Chen, TH, Liou, CM, Chou, MC, Hung, WT. Retrospective analysis of surgery postponed or cancelled in the operating room. J Clin Anesth. 2010;22(4):237–40.Google Scholar
9. Haana, V, Sethuraman, K, Stephens, L, Rosen, H, Meara, JG. Case cancellations on the day of surgery: an investigation in an Australian paediatric hospital. ANZ J Surg. 2009; 79(9):636–40.Google Scholar
10. Gonzalez-Arevalo, A, Gomez-Arnau, JI, delaCruz, FJ, et al. Causes for cancellation of elective surgical procedures in a Spanish general hospital. Anaesthesia. 2009;64(5):487–93.Google Scholar
11. Garg, R, Bhalotra, AR, Bhadoria, P, Gupta, N, Anand, R. Reasons for cancellation of cases on the day of surgery-a prospective study. Indian J Anaesth. 2009;53(1):35–9.Google Scholar
12. Schofield, WN, Rubin, GL, Piza, M, et al. Cancellation of operations on the day of intended surgery at a major Australian referral hospital. Med J Aust. 2005;182(12):612–15.CrossRefGoogle Scholar
13. Kumar, R, Gandhi, R. Reasons for cancellation of operation on the day of intended surgery in a multidisciplinary 500 bedded hospital. J Anaesthesiol Clin Pharmacol. 2012;28(1):66–9.Google Scholar
14. McIntosh, B, Cookson, G, Jones, S. Cancelled surgeries and payment by results in the English National Health Service. J Health Serv Res Policy. 2012;17(2):79–86.CrossRefGoogle ScholarPubMed
15. Argo, JL, Vick, CC, Graham, LA, Itani, KM, Bishop, MJ, Hawn, MT. Elective surgical case cancellation in the veterans health administration system: identifying areas for improvement. Am J Surg. 2009;198(5):600–6.CrossRefGoogle ScholarPubMed
16. Robb, WB, O'sullivan, MJ, Brannigan, AE, Bouchier-Hayes, DJ. Are elective surgical operations cancelled due to increasing medical admissions? Ir J Med Sci. 2004;173(3):129–32.Google Scholar
17. Schuster, M, Neumann, C, Neumann, K, et al. The effect of hospital size and surgical service on case cancellation in elective surgery: results from a prospective multicenter study. Anesth Analg. 2011;113(3):578–85.Google Scholar
18. Hovlid, E, Bukve, O, Haug, K, Aslaksen, AB, von Plessen, C. A new pathway for elective surgery to reduce cancellation rates. BMC Health Serv Res. 2012;12(1):154.Google Scholar
19. Pandit, JJ, Carey, A. Estimating the duration of common elective operations: implications for operating list management. Anaesthesia. 2006;61(8):768–76.CrossRefGoogle ScholarPubMed
20. Pandit, JJ, Tavare, A. Using mean duration and variation of procedure times to plan a list of surgical operations to fit into the scheduled list time. Eur J Anaesthesiol. 2011; 28(7):493–501.Google Scholar
21. Tung, A, Dexter, F, Jakubczyk, S, Glick, DB. The limited value of sequencing cases based on their probability of cancellation. Anesth Analg. 2010;111(3):749–56.Google Scholar
22. Purzner, T, Purzner, J, Massicotte, EM, Bernstein, M. Outpatient brain tumor surgery and spinal decompression: a prospective study of 1003 patients. Neurosurgery. 2011;69(1):119–26; discussion 126-7.Google Scholar
23. Boulton, M, Bernstein, M. Outpatient brain tumor surgery: innovation in surgical neurooncology. J Neurosurg. 2008;108(4):649–54.Google Scholar
24. Carrabba, G, Venkatraghavan, L, Bernstein, M. Day surgery awake craniotomy for removing brain tumours: technical note describing a simple protocol. Minim Invasive Neurosurg. 2008;51(4):208–10.Google Scholar
25. Oakley, J. Surgeon report cards, clinical realities, and the quality of patient care. Monash Bioeth Rev. 2009;28(3):21.1–21.6.Google Scholar
26. Neil, DA, Clarke, S, Oakley, JG. Public reporting of individual surgeon performance information: United Kingdom developments and Australian issues. Med J Aust. 2004; 181(5):266–8.CrossRefGoogle ScholarPubMed
27. Hasman, A, Holm, S. Accountability for reasonableness: opening the black box of process. Health Care Anal. 2005;13(4):261–73.Google Scholar
28. Reeleder, D, Martin, DK, Keresztes, C, Singer, PA. What do hospital decision-makers in Ontario, Canada, have to say about the fairness of priority setting in their institutions? BMC Health Serv Res. 2005;5(1):8.Google Scholar
29. Martin, DK, Singer, PA, Bernstein, M. Access to intensive care unit beds for neurosurgery patients: a qualitative case study. J Neurol Neurosurg Psychiatry. 2003;74(9):1299–303.CrossRefGoogle ScholarPubMed
30. Kapiriri, L, Norheim, OF, Martin, DK. Fairness and accountability for reasonableness. Do the views of priority setting decision makers differ across health systems and levels of decision making? Soc Sci Med. 2009;68(4):766–73.Google Scholar
31. Maluka, SO. Strengthening fairness, transparency and accountability in health care priority setting at district level in Tanzania. Glob Health Action. 2011; 4:10.3402/gha.v4i0.7829. Epub 2011 Nov 7.CrossRefGoogle ScholarPubMed
32. Stafinski, T, Menon, D, McCabe, C, Philippon, DJ. To fund or not to fund: development of a decision-making framework for the coverage of new health technologies. Pharmacoeconomics. 2011;29(9):771–80.Google Scholar
33. Schlander, M. The use of cost-effectiveness by the National Institute for Health and Clinical Excellence (NICE): no(t yet an) exemplar of a deliberative process. J Med Ethics. 2008;34(7):534–9.Google Scholar
34. Cooper, AB, Joglekar, AS, Gibson, J, Swota, AH, Martin, DK. Communication of bed allocation decisions in a critical care unit and accountability for reasonableness. BMC Health Serv Res. 2005;5:67.Google Scholar
35. Gibson, JL, Martin, DK, Singer, PA. Priority setting in hospitals: fairness, inclusiveness, and the problem of institutional power differences. Soc Sci Med. 2005;61(11):2355–62.CrossRefGoogle ScholarPubMed
36. Daniels, N, Sabin, JE. Accountability for reasonableness: an update. BMJ. 2008;337:a1850.Google Scholar
37. Ibrahim, GM, Fallah, A, Snead, OC 3rd, et al. Ethical issues in surgical decision making concerning children with medically intractable epilepsy. Epilepsy Behav. 2011;22(2):154–7.CrossRefGoogle ScholarPubMed
38. Ibrahim, GM, Barry, BW, Fallah, A, et al. Inequities in access to pediatric epilepsy surgery: a bioethical framework. Neurosurg Focus. 2012;32(3):E2.Google Scholar
39. Harris, J. QALYfying the value of life. J Med Ethics. 1987;13(3):117–23.Google Scholar
40. Harris, J. Life: quality, value and justice. Health Policy. 1988;10(3):259–66.Google Scholar
41. Gruskin, S, Daniels, N. Process is the point: justice and human rights: priority setting and fair deliberative process. Am J Public Health. 2008;98(9):1573–7.Google Scholar