Placing patients in the queue for coronary surgery
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Objective:To determine the effects of age and work status on whether and where cardiovascular specialists would place hypothetical patients in the queue for coronary surgery.
Materials and methods:Mailed survey presenting a set of clinical scenarios either to be rated on a scale with 7 time frames for urgency of need or to be designated as questionable/inappropriate for intervention. The basic scenario was a patient with mild-moderate stable angina, good left ventricular function, and limited coronary disease; operative risks and stress test results were varied. Three identifiers were used: “45-year-old civil servant gainfully employed”; “45-year-old laborer disabled by angina, faces job loss”; and “75-year-old retiree, angina limits golf.”
Participants:Cardiologists and cardiac surgeons practicing in five Ontario medical centers (n=120).
Results:There was a 59% response rate (120 usable responses). Large shifts in willingness to intervene occurred in favor of the disabled laborer (p<0.0001) and against the retiree (p-value ranges from 0.04 to <0.0001, depending on operative risk and stress test results), but not for the employed civil servant. Striking effects (p<0.0001) were also evident in ratings of waiting time, with the order of priority being the disabled laborer first, the civil servant second, and the retiree last. The overall mean shift due to work status or age was equal to, or larger than, the mean shift due to clinical factors, such as stress test results, changes in severity of stable angina, and extent of coronary disease.
Conclusion:Cardiovascular specialists may place considerable weight on age and work status in determining urgency and appropriateness of coronary revascularization. Risk-benefit concerns may partly explain shifting thresholds for intervention, but not differential waiting times. The influence of these factors should be sought in utilization audits and addressed from an ethical perspective.
Key wordsrationing waiting lists appropriateness coronary artery bypass grafting health policy coronary revascularization decision making
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