Single-entry models:
value and acceptability among
orthopaedic surgeons in Canada
March 28, 2012
Taming of the Queue
Pre-Conference Workshop
Zaheed Damani
Dr. Barbara Conner-Spady
Dr. Tom Noseworthy
Overview
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Single-Entry Models: an introduction
Patient views
Surgeon views
Critical success factors
Discussion
Background on waiting times
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Access
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Waiting times (WTs) are an issue in most health systems,
particularly in universal health care (Siciliani & Hurst, 2003)
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WTs can be reduced
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Demand > Supply
Many strategies exist, varying effects/results, no
clear solution
Elective procedures
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Hip and Knee replacement; 26 wks
Current State of Waiting
i.e. complaints of joint pain
GP
GP
GP
GP
GP
GP
GP
Patient
Patient
Patient
Patient
Patient
Patient
Patient
Consultation
Specialist 1
Misdiagnosis / do not qualify
Specialist 2
Specialist 3
•Some do not qualify
•Some are severe
•Some wait
Surgery
Current State of Waiting
Patient
Patient
Patient
Patient
Patient
Patient
Specialist 1
Specialist 2
Specialist 3
Single-entry models
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1 line/10 tellers vs. 10 lines/10 tellers
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Patient
Banks, Airlines, Restaurants, Health
care?
Patient
A single queue
Patient
Centralised intake/single point of entry
 Pooled list
 Triage/screening
Waiting lists pooled, patients treated by a
pool of surgeons on a first come, first served
basis, or adjusted for urgency
Patient
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Example: Hip and Knee clinics
 Calgary, Edmonton, Red Deer
 Nova Scotia, Winnipeg
Specialist 1
Patient
Patient
Specialist 2
Specialist 3
Patient
Patient
Patient
Patient
Patient
Patient
Patient
Patient
Patient
Patient
Specialist 1
Specialist 2
Specialist 3
Patient
Patient
Specialist 1
Specialist 2
Specialist 3
Profile: Edmonton Hip and Knee Clinic
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Pooled list: Patients have the option of seeing the
next-available surgeon, or a named surgeon of their
choice
Single Entry: All patient referrals are sent to the
H&K clinic
Triage: Referrals are evaluated for priority and
urgency; sent to the appropriate surgeon
Surgeon conducts consult at the H&K Clinic
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Majority of surgeons participate
One-stop shop for patients awaiting H&KR
Current knowledge about SEMs
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Evidence base
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Patient
Ten studies in the literature
Currently employed in CAN/AUS/UK
Promising evidence
 Potential for equity, reduced WTs, costs,
little patient impact
Not high level evidence – no RCT or
comparative studies
Patient
Patient
Patient
Patient
Patient
Gaps / Motivation for this work:
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Questions remain about
acceptability among patients
and clinicians
This is important to understand
Specialist 1
Specialist 2
Specialist 3
The unspoken agreement…
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SEMs currently in use:
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Patients need to agree to go through the same
door
Surgeons need to be on board to receive them in
such a fashion, on the other side
What remains to be studied?
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What do both think about this?
How can their acceptability of this model be
increased?
What have patients told us?
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Spady et al.
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Focus groups conducted in Calgary, Winnipeg, Toronto,
Halifax (n = 114)
Questionnaire administered as well
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Choice based on trust and reputation
Virtually divided on seeing the next-available
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Acceptability of being placed on a waiting list to be seen by the
next available orthopedic surgeon
Must be equally qualified and waiting time reduction of at least
1 month
Would be willing to see next-available if pain or
urgency required it
What about surgeons?
Are single-entry models acceptable to
orthopaedic surgeons receiving referrals
for H&KR?
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Under what conditions?
Study Methods
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19 Experienced surgeons recruited
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11 Alberta (8U/3R), 4 Manitoba (3U/1R), 4 Nova Scotia (4U)
11 Academic & 8 Community-based
15 Urban and 4 Rural
Semi-structured interviews (telephone)
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Structured and open-ended questions
Thematic analysis used to code, classify and interpret the
findings
2 coders
Results
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68% of surgeons accept patients from a pooled
list
89% familiar with SEMs
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84% initially rated as acceptable
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93% among urban, 60% among rural
Between 30 – 42 unique themes discussed in
each of the 6 open-ended questions
Acceptability was not universal; there are
caveats
Results
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Classified into 5 broader aggregate themes:
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Patient Experience
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Ability to retain choice
Evaluation
Physician Involvement
Management
Resources
1. Physician Involvement
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Common to both rural and urban surgeons:
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Continuity of Care
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Trust, relationship are important in surgery
 Implication for outcomes
Concerns with lack of continuity of care
Pooling for surgery vs. consultation
 Feeling reduced to a “technician”
Competence and trust among surgeons
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Optional participation / inclusion
Concerns over the skill of those involved
 Quality monitoring to improve performance
2. Management
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Praise for Screening; concerns over case mix
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Appropriate for surgery; yield
Minimum case-loads
Urban vs. Rural
Pooling for consultation
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Vehement opposition to pooling for surgery
Enables continuity of care
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Calls for optional surgeon participation
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Desire for autonomy to make clinical decisions,
contribute to care path
3. Resources
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Strong praise for staff / multidisciplinary team
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Improves patient care, experience
Reduces demand on surgeons’ time
Concerns over funding
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To increase clinical capacity
To maintain screening
Balancing priorities (general vs. specialist)
Critical Success Factors
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Allow patients to retain an ability to choose
Allow surgeons optional involvement; ability to
maintain choice, ability to make final clinical
decisions (i.e. for surgery)
Centralised triage, intake and streamlined
management is a must, with fair distribution and
matching of cases to surgeons
Lists should never be pooled for surgery, only
consults
Consistent, predictable funding to support
screening, staff
Government commitment towards achieving
agreed-upon benchmarks
Discussion
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Surgeon opinions differ, generally in favour of SEMs /
status quo; acceptability is not universal
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Critical success factors will enhance acceptability
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Consideration of these factors could improve existing SEMs
Possible generalisability to other elective procedures
Findings consistent with literature
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Rural vs urban
2 studies from the UK – spinal surgery and ophthalmology
Further research – GPs, policy makers
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Controlled studies
Thank you
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Questions?
Surgeon Interviews
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We asked 6 questions:
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What aspects of SEMs do you agree / disagree with?
What factors/incentives would be important to you and your
patients to make single-entry models acceptable?
What factors/circumstances would cause you to oppose
single-entry models?
What kinds of practice characteristics or administrative
supports would be needed for the implementation of singleentry models?
If we were discussing the implementation of single-entry
models in your practice, to what extent would you be in favour
of implementing single-entry models?