ANZ J. Surg.

2003;

73

: 839–842

ORIGINAL ARTICLE

ORIGINAL ARTICLE

CLINICAL CATEGORIZATION FOR ELECTIVE SURGERY IN VICTORIA

C

OLIN

R

USSELL

,* M

AREE

R

OBERTS

,

‡

T

IMOTHY

G. W

ILLIAMSON

,

‡

J

ANE

M

C

K

ERCHER

,

‡

S

IMON

E. J

OLLY

‡

AND

J

OHN

M

C

N

EIL

†

*Peninsula Health and Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Monash Medical Centre and

†

Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Alfred Hospital and

‡

Department of Human Services, Melbourne, Victoria, Australia

Aim:

The aim of the present paper was to assess trends in clinician’s utilization of urgency categories for elective surgery.

Methods:

The present paper reviews the additions to the Victorian elective surgery waiting list for hip replacement and prostatec-tomy as recorded by the Elective Surgery Information System database. Review of general trends in utilization over two separate12 month periods were undertaken.

Results:

There is inconsistency in categorization of patients referred to the waiting list for hip joint replacement and prostatec-tomy. An increasing trend to categorize patients as semi-urgent (category 2) in preference to non-urgent (category 3) emerged overthis period (category creep). Semi-urgent cases might be competing for access within the category 2 band with less urgent cases.

Conclusions:

There seems to be an increasing imbalance between demand for and availability of elective surgery for lowerurgency elective surgical procedures. This imbalance, characterized by lengthening waiting times, means that not all patients willreceive treatment within the clinically recommended waiting times. The variable approach to categorization of urgency suggests thatthe process lacks objectivity and consensus. Simple clinical tools to assist prioritization are currently being evaluated in Victoria(Australia) and other countries.

Key words: elective surgical procedure, waiting list.

Abbreviations

: Cat. 1, category 1; cat. 2, category 2; cat. 3, category 3; DHS, Department of Human Services; ESIS, ElectiveSurgery Information System; WCWL, Western Canada Waiting List Project.

INTRODUCTION

Waiting lists, or more precisely, waiting times, for electivesurgery are a contentious issue. Their magnitude is dependent onthe balance between the demand for surgical services and theiravailability. The existence of waiting lists implies a demand thatexceeds the capacity or willingness to supply. Prolonged waitingtimes are typically concentrated among the procedures wheretreatment can be tolerably deferred or those that are seen as rela-tively discretionary.

Waiting lists do provide hospitals with the means to achievefull utilization of their facilities by creating a pool of patients,which smoothes fluctuating demand.

1

In a private market system,the demand denoted by a substantial waiting list would generallylead to an increase in service provision or in the price charged forthese services. In the current public sector model, incentives suchas these are absent and there is, therefore, less opportunity toregulate supply or demand. However, waiting lists are generally apolitically sensitive issue and any substantial increase in waitingtimes can lead to the provision or redirection of resources.

Equity of access is a fundamental requirement of any publiclyfunded health-care system. The existence of waiting lists makes itnecessary to institute mechanisms to prioritize access to surgicalservices in a way that is both transparent and fair. This issue hasrecently been addressed by The Council of Europe, which hasdefined principles for managing access to elective surgery.

2

These principles include objectivity, equity, reproducibility andtransparency in selection of patients for treatment.

In Victoria a system of categorization of clinical urgency forelective surgery has existed for some years but its relative meritsand its ability to meet the desired criteria (see above) have notbeen formally assessed. We have used the Victorian waiting listdatabase (see below) to examine trends in Victorian waiting listsand to study the utilization of urgency categories for two commonelective surgical procedures with long waiting times – jointreplacement and prostatectomy. The findings have been used tosupport a case for additional research into ways to prioritizepatients awaiting surgical procedures

METHODS

Background to current prioritization system

In 1991 the Health Department of Victoria, in consultation withits clinical advisory group

3

introduced a clinical urgency cate-gorization system for elective surgery. The system, shown below,established clinically desirable waiting times (urgency profiles)for each of the three categories and has been in use across thespectrum of elective surgery for 10 years.

Category 1 (Cat. 1) – Urgent

Admission within 30 days is desirable for a condition that has thepotential to deteriorate quickly to the point that it might becomean emergency.

Associate Professor Colin Russell is chairman of the Victorian AdvisoryCommittee on Access for Elective Surgery (ACAES), an advisory committee ofthe Department of Human Services (DHS). The views expressed in this paper arepersonal and not necessarily those of the Department of Human Services.

C. Russell

MS, FRACS;

M. Roberts

MA (Hons) BA;

T. G. Williamson

BSc (Hons), PhD;

J. McKercher

;

S. E. Jolly

PhD;

J. McNeil

PhD, FRACP.

Correspondence: Associate Professor Colin Russell, Director of Surgery,Peninsula Health, Hasting’s Road, Frankston, Vic. 3199, Australia.Email: crussell@phen.vic.gov.au

Accepted for publication 28 May 2003.

840 RUSSELL

ET AL

.

Category 2 (Cat. 2) – Semi-urgent

Admission within 90 days is desirable for a condition causingsome pain, dysfunction or disability but which is not likely todeteriorate quickly or become an emergency.

Category 3 (Cat. 3) – Non-urgent

Admission at some time in the future is acceptable for a conditioncausing minimal or no pain, dysfunction or disability, which isunlikely to deteriorate quickly and that does not have the poten-tial to become an emergency.

The above are now national data definitions. Perceived urgencyof need for care has been distributed among three bands, each witha recommended waiting time. With the exception of New SouthWales, which has a fourth category (patients requiring surgerywithin 7 days), all other states and territories use this system.

Assignment to prioritization categories

The appropriate urgency category is assessed by the referringspecialist at the time a patient is referred to the waiting list. It is arequired field that must be documented before a patient isaccepted onto the hospital waiting list. Since 1998 it has been arequirement for hospitals to submit data, on a monthly basis, tothe Elective Surgery Information System (ESIS). This is a centraldatabase, maintained by the Victorian Department of HumanServices (DHS). The DHS provides strong financial incentives toensure that no cat. 1 patients wait longer than 30 days for treat-ment and publishes quarterly reports on trends in waiting listnumbers, waiting times, categorization and elective surgerythroughput from this database.

4

Data extraction

The utilization of urgency categories for two common electivesurgical procedures with long waiting times, joint replacementand prostatectomy, was studied. The data presented below havebeen extracted from the ESIS files. Information was sought con-cerning the total numbers of patients awaiting elective surgeryand trends in numbers and waiting times within the three waitinglist categories. Information on the urgency categories of patientsat the time of referral for total hip replacement or prostatectomyto the waiting lists of specific hospitals was extracted.

Advice from one of the authors (J McNeil) – chairman ofresearch and ethics committee of a major health service – con-firmed that since identifiable information was not used, EthicsCommittee endorsement of the project was not necessary.

RESULTS

Figure 1 shows the trend in the total number of patients awaitingadmission for elective surgery in Victoria between 1 July 1998and 30 June 2001. Over this time waiting list numbers haveincreased and reached a peak of just over 44 000 in January 2001.However, in the last 6 months of 2001 they declined to below42 000.

Table 1 shows the number of patients admitted from the electivesurgery waiting list in Victoria during the 12 month periods of1998 and 1999 and 2000 and 2001 and their waiting list categories.Between these two periods the total annual admissions for electivesurgery declined by 13 652 (11%). The throughput of electivepatients assigned to cat. 1 actually increased by 3.6% but the per-centage of cat. 2 and 3 patients admitted fell by 2.7% and 6.3%,respectively. Almost half the patients admitted for surgery from theelective waiting list in 2000–2001 had been assigned to cat. 2.

Table 2 shows the number of patients added to each of thethree waiting list categories during the 12 month periods of 1998and 1999 and 2000 and 2001. The most evident features are the10.1% increase in the number of patients assigned to cat. 2 andthe 11.8% decrease in assignment to cat. 3. The percentage ofpatients allocated to cat. 1 showed a more minor change. Averagewaiting times for surgery for patients in cat. 2 and 3 alsoincreased over this time (Fig. 2) in keeping with the decrease inthe total numbers admitted for elective surgery.

Figures 3 and 4 show the distribution of urgency categories forpatients placed on the waiting lists of metropolitan and majorrural hospitals for two specific procedures – total hip replacementand prostatectomy – between 1 July 2000 and 30 June 2001.These varied greatly among the 19 hospitals. Clinicians from hos-pital 1 in Fig. 3 (at the top of the chart) categorized >20% of theirpatients in need of total hip replacement as cat. 1, whereas clini-cians from hospital 19 (at the bottom of the chart) placed nopatients in this category. The allocation of patients to cats 2 and 3also show marked variation among hospitals.

Fig. 1.

Total number of patients waiting for elective surgery from1 July 1998 to 30 June 2001.

Table 1.

Number of patients and percentage by category admitted from the elective surgery waiting list in two separate years

Urgency category No. (% of total) patients admitted from waiting list Change in patient numbers (change in %) 1998–1999 2000–2001

1 20 253 (16.3%) 21 962 (19.9%) +1709 (+3.6%)2 56 725 (45.7%) 53 450 (48.4%) –3275 (–2.7%)3 47 059 (38%) 34 973 (31.7%) –12 086 (–6.3%)Total 124 037 110 385 –13 652

ASSESSING URGENCY FOR CARE 841

The categorization profile for patients awaiting prostatectomy(Fig. 4) shows a similar variation.

Figures 3 and 4 also demonstrate that these trends in cate-gorization are not hospital specific, with the distribution of cat. 1,2 and 3 varying by procedure, rather than suggesting a constanttrend within any specific hospital.

DISCUSSION

The data presented were derived from an information system(ESIS) that facilitates close monitoring of trends in access to elec-tive surgery in Victoria. The results have shown an increase inwaiting list numbers, particularly among patients assigned to cat.2. Numbers waiting in cat. 3 have also increased to a lesser extentand waiting times for both categories have increased. The datasuggest a major category creep, with an increasing proportion ofpatients assigned by their clinicians to cat. 2 rather than cat. 3.

The data presented also suggest that clinicians from differenthospitals are inconsistent in their allocation of clinical urgencycategories, at least in the two major categories for electivesurgery examined in the present study. The burden of diseasemanaged by these hospitals is unlikely to be sufficiently differentto account for the variations in categorization observed. The dif-ferences probably result from variation in the clinicians approachto, and interpretation of, the current categorization system. Thisvariability has made it easy for category creep to occur over time.

Given the relatively vague distinction between cats 2 and 3 it isnot surprising that clinicians are increasingly reducing the pro-

portion of patients they allocate to cat. 3; considering that thewaiting time for patients in cat. 3 now averages approximately10 months (rather than 3 months for cat. 2). The resulting ten-dency to classify more patients into cat. 2 rather than cat. 3 mightcause waiting times for true semi-urgent cases, within the cat. 2band, to increase beyond acceptable limits. Ninety-nine per centof cat. 1 patients are admitted within the target (30 days),

4

sug-gesting that the system does ensure timely treatment for thoseperceived to have the most urgent need for care.

Variations in urgency categorization are also evident on anational scale.

5

The allocation of patients to urgency cat. 1 variesfrom 16.3% in Victoria to 43.6% in Tasmania. Differences inseverity of disease within these states is again unlikely to explainthis variation and suggests that the difference lies in the inter-pretation and application of the national data definitions amongindividual clinicians.

The relationship between severity of illness and waiting timefor elective surgery has previously been shown to be tenuous.

6–8

A study conducted in an area health service in New South Waleshas shown that although waiting time was strongly associatedwith the urgency rating given by the surgeon

7

a number of otherfactors – surgical specialty, health insurance status and employ-ment status – appeared to exert an additional and independentinfluence on waiting time. Informal guidelines for prioritizingurgency of surgery have existed for some years but none hasgained national acceptance.

The problems associated with long waiting lists and their man-agement have been observed in many countries with publicly

Fig. 2.

Average waiting times for cat. 2 and 3 patients between July1998 and May 2001.

�

, cat. 2;

�

, cat. 3.

Fig. 3.

Distribution between urgency categories among metro-politan and major rural hospitals of patients placed on the waiting listfor total hip replacement between 1 July 2000 and 30 June 2001.

�

,cat. 1; , cat. 2;

�

, cat. 3.

Table 2.

Number and percentage of patients by category added to elective surgery waiting list during one full year 1998–1999 and 2000–2001

Urgency category No. (% of total) patients added to elective surgery waiting list Change in patient numbers (change in %) 1 July 1998–30 June 1999 1 July 2000–30 June 2001

1 29 447 (5.7%) 34 647 (7.4%) 5200 (+1.7%)2 190 172 (36.5%) 216 581 (46.6%) 26 409 (+10.1%)3 300 793 (57.8%) 213 847 (46.0%) –86 946 (–11.8%)Total 520 412 465 075 –55 337

842 RUSSELL

ET AL

.

funded health services.

9

Equity of access to health care is a majorplank of the Australian Health Care Agreement and other publichealth systems. Where allocated resources do not meet demand forservices, the goal should be provision of care to those with the mosturgent needs and ability to benefit. The present study suggeststhat the current Victorian (and Australian) urgency categorizationsystem for elective surgery might be unable to recognize this goal.

Some countries, particularly New Zealand and Canada, haveseen benefit in developing appropriate guidelines and priorityscoring systems in an attempt to make prioritization more con-sistent and reproducible.

10–13

Experience to date suggests onlylimited success with these approaches.

14

However, as experienceincreases, it is hoped that refinement of the methodology willcreate a more robust and useful system of prioritization.

The ability to categorize urgency for specific clinical conditions,such as joint replacement, prostatectomy and cataract removal, isan important first step. It is likely to prove a more readily attainablegoal than attempting categorization across the entire spectrum ofelective surgery. However, it will become necessary to attempt amore global approach to prioritization, if only to allow a rationalallocation of resources among different clinical specialty areas.

Preliminary validation studies by the Western Canada WaitingList Project (WCWL)

11

of a clinical categorization tool for priori-tizing urgency for joint replacement have been encouraging. In acollaborative project with local clinicians we have made somenecessary but minimal adaptations to this WCWL categorizationtool. A study to test and validate this revised tool under localconditions is near completion. Using the same collaborativeapproach we have developed a categorization tool for patientsawaiting prostatectomy. This is currently being evaluated usingsimilar methodology. The results of these studies and a review ofthe current status of clinical categorization will be published sep-arately. We are also investigating the attributes of, and canvass-ing opinion on, replacing the current three urgency bands with afour category system.

In summary this study has shown:• An inconsistent approach to categorization of urgency

among specialists for individual conditions/procedures (jointreplacement and prostatectomy)

• An increasing trend to categorize patients as semi-urgent(cat. 2) in preference to non-urgent (cat. 3) is emerging (category

creep). Semi-urgent cases might be competing for access withinthe cat. 2 band with non-urgent cases.

The data also indicate an increasing imbalance between demandfor, and availability of access to elective surgery for lower urgencyelective procedures. This imbalance, characterized by lengtheningwaiting times, means that not all patients will receive treatmentwithin the clinically recommended waiting times. The variableapproach to categorization of urgency might suggest that referringspecialists are failing to meet the desired criteria of objectivity,equity, reproducibility and transparency in the management ofdemand for elective surgery. Part of the approach taken to resolvethis issue will involve the use of more precise, reproducible andvalid instruments to assist prioritization, such as those that are cur-rently being evaluated in Victoria and in other countries.

ACKNOWLEDGEMENTS

The authors wish to acknowledge support from the following:the Victorian Department of Human Services for the provision ofdata and support for Colin Russell during his recent sabbaticalleave and the Advisory Committee on Access for Surgery, whosesearch for trends within available waiting list data has brought tolight the problems with the current categorization system.

REFERENCES

1. Worthington D. Hospital waiting list management models.

J. Oper.Res. Soc.

1991;

42

: 833–43.2. Council of Europe.

Recommendation No R.(99)21, Health andquality of life

, 1998. Available from URL: http://www.social.coe.International/en/QofLife/recomm/R.(99)21.htm. Accessed on:30 June 2002.

3. Collopy B. What is the truth about surgical waiting lists?

Med. J.Aust.

1998;

169

: 453–4.4. Department of Human Services.

Hospital Services Report

. Mel-bourne: Department of Human Services; 2001.

5. Australian Institute of Health and Welfare (AIHW).

WaitingTimes for Elective Surgery in Australia 1998–99

. Report no.AIHW cat, no. HSE 13. Canberra: AIHW, 2001.

6. Pope C, Roberts J, Black N. Dissecting a waiting list.

HealthServ. Manage. Res.

1991;

4

: 112–19.7. Clover K, Dobbins T, Smyth T, Sanson-Fisher R. Factors associ-

ated with waiting time for surgery.

Med. J. Aust.

1998;

169

:464–8.

8. Harry L, Nolan J, Elender F, Lewis J. Who gets priority?Waiting list assessment using a scoring system.

Ann. R. Coll.Surg. Engl.

2000;

82

: 186–8.9. Devlin N, Harrison A, Derrett S. Waiting in the NHS. Part 1:

a diagnosis.

J. R. Soc. Med.

2002;

95

: 223–6.10. Derrett S. Surgical prioritisation and rationing: some recent

changes.

NZ Bioethics J.

2001;

2

: 3–6.11. Western Canada Waiting List Project.

From Chaos to Order:Making Sense of Waiting Lists in Canada. Final report

, 2001.Available from URL: http://www.wcwl.org/graphics/finalrpt.pdf.

12. Gauld R, Derrett S. Solving the surgical waiting list problem?New Zealand’s ‘booking system’.

Int. J. Health Plann. Manage.

2000;

15

: 259–72.13. McGurran T, Noseworthy T. Improving the management of

waiting lists for elective healthcare services: public perspectiveson proposed solutions.

Hosp. Q.

2002;

5

: 28–32.14. Derrett S, Devlin N, Harrison A. Waiting in the NHS, Part 2:

a change of prescription.

J. R. Soc. Med.

2002;

95

: 280–3.

Fig. 4.

Distribution between urgency categories among metro-politan and major rural hospitals of patients placed on the waiting listfor prostatectomy between 1 July 2000 and 30 June 2001.

�

, cat. 1;, cat. 2;

�

, cat. 3.