waiting for elective surgery: effect on physical ... - Wiley Online Library

ANZ J. Surg. 2007; 77: 892–898

doi: 10.1111/j.1445-2197.2007.04268.x

RISK MANAGEMENT

WAITING FOR ELECTIVE SURGERY: EFFECT ON PHYSICAL PROBLEMS AND POSTOPERATIVE RECOVERY JURRIAAN P. OUDHOFF,* DANIELLE R. M. TIMMERMANS,* DIRK L. KNOL,† ALBERT B. BIJNEN‡ AND GERRIT VAN DER WAL* *Department of Public and Occupational Health, Institute for Research in Extramural Medicine and †Department of Clinical Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, and ‡Department of Surgery, Medical Centre Alkmaar, Alkmaar, the Netherlands Background: Long waiting times for elective surgery pose a threat to the quality of care. Our study aimed to assess (i) the physical symptoms and disabilities patients experience during the wait, (ii) the perceived improvements after surgery and (iii) whether problems increase during the wait or longer waits affect postoperative outcomes. Methods: A cross-sectional questionnaire study with postoperative follow up was held among patients waiting for surgery of varicose veins (n = 176), inguinal hernia (n = 201) and gallstones (n = 128) in 27 hospitals. Results: During the wait, each group reported increased levels of pain and impaired mobility (Nottingham Health Profile, P < 0.05). However, 15–41% of patients had no or mild symptoms, whereas 5% of inguinal hernia patients had severe pain and 17% of gallstone patients reported ‡1 colic attacks per week. Surgery resolved symptoms in 86–95% of patients. The length of the wait was not associated with problems during the wait or with postoperative outcomes (multilevel regression analysis, P > 0.01). Conclusions: Waiting for general surgery primarily prolongs the suffering from symptoms, which are relieved by surgery. Although the prioritization of patients with more severe symptoms would reduce the overall burden of waiting, patients with minimal symptoms may be advised to refrain from surgery. Key words: quality of health care, quality of life, surgery, waiting list.

Abbreviation: NHP, Nottingham Health Profile.

INTRODUCTION General surgery traditionally comprises a case mix of patients who need emergency care, urgent surgery or elective treatment. As a result of increased overall demand of care and a restricted level of supply, patients are now required to wait long times before receiving elective surgery in various countries.1–4 Along with rising waiting times, the public and professional concern about the possible negative consequences of long delays of needed treatment for patients has grown. Although studies subsequently addressed the outcomes of waiting for cardiac and orthopaedic surgery,5–9 to date there is little finding on the effect of waiting for elective general surgery.10 Although some studies report on specific risks of waiting, the burden that arises from being on a surgical waiting list is mostly unclear and it is difficult to assess whether current waiting times are compatible with highquality health care.11–18 Our study aims to provide an insight into the physical effect of being on a waiting list for the most frequently carried out operaJ. P. Oudhoff PhD; D. R. M. Timmermans PhD; D. L. Knol PhD; A. B. Bijnen MD, PhD; G. Van der Wal MD, PhD. Correspondence: Dr Jurriaan P. Oudhoff, Department of Public and Occupational Health, Institute for Research in Extramural Medicine, VU University Medical Centre, vd Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands. Email: [email protected] Accepted for publication 23 January 2007. 2007 The Authors Journal compilation 2007 Royal Australasian College of Surgeons

tions in general surgery, namely elective treatment of varicose veins, inguinal hernia and gallstones. Specifically, the purpose of this study is to assess (i) the condition-specific and generic physical symptoms and disabilities patients experience during the wait; (ii) the outcomes after the wait, that is, the perceived improvements after surgery and the duration of postoperative recovery and (iii) the effect of the length of the wait on the symptoms and disabilities during the wait and on postoperative recovery.

METHODS Participants and procedure The study was a cross-sectional questionnaire study with postoperative follow up of the respondents. Surgical departments of 27 general hospitals with ‡400 beds and situated across the Netherlands participated. At a visit to each hospital between June 2001 and January 2002, we made an inventory of the adult patients (aged ‡18 years) registered as waiting for elective treatment of varicose veins, inguinal hernia or gallstones. Patients who were scheduled for surgery within 2 weeks after the visit were excluded for logistic reasons. Patients were also excluded when it was registered that surgery was delayed on the patient‘s request or that the patient’s fitness for surgery was yet to be assessed (e.g. as a result of comorbidity). The details of eligible patients mentioned here were recorded: the date of registration on the waiting list, age and sex. Eligible patients were sent information about the

EFFECT OF WAITING FOR ELECTIVE SURGERY

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study and an invitation to participate on behalf of a local surgeon. A reminder was sent out after 2 weeks. A preoperative postal questionnaire was dispatched to patients who returned a signed consent form. To assess the date of surgery of the patients who participated, we regularly contacted the surgical departments of the participating hospitals during the study. A postoperative questionnaire was sent to each participant 90 days (–1 week) after the date of surgery. The study was approved by the VU University Medical Centre medical ethics committee.

concerning activities without any problems. All items were to be answered on a 5-point Likert-type scale resulting in scores between 0 and 20 for varicose veins and 0 and 25 for inguinal hernia and gallstones. As a generic measure for physical disability, we used the scale on physical mobility from the NHP.19–21 This scale consists of eight items covering problems with mobility with answering options ‘yes’ and ‘no’. Each positively answered item adds to a score ranging from 0 to 8, with higher scores indicating more problems with mobility.

Non-response analysis

Duration of postoperative recovery This was addressed by one question on the time it took to fully recover from surgery (six response categories ranging from ‘recovery within one week’ to ‘not fully recovered yet’).

A non-response analysis was conducted in a selection of nine participating hospitals. Local hospital employees contacted the patients who had not returned the consent form by telephone and asked the reason for not responding using a short structured questionnaire. Questionnaire/measures Patient characteristics In addition to questions pertaining to standard details of patients, participants were asked to record the date on which they completed the questionnaires and whether surgery was (to be) provided on an inpatient or outpatient basis. Symptoms To assess the condition-specific symptoms while waiting, we asked the patients with varicose veins what symptoms would occur when they would stand upright for 1.5 h and whether a complication (eczema, phlebitis, varicose haemorrhage and venous ulcer) had been present in the 4 weeks before completing the questionnaire. Patients with inguinal hernia were asked which symptoms lifting 10 kg would provoke. Patients with gallstones were asked to report the number of colic attacks in the past 4 weeks. After surgery, participants were asked to which extent their symptoms were relieved by surgery (five response categories ranging from ‘completely’ to ‘not at all’). To assess the level of pain as a generic measure for symptom severity, we gave the scale for pain from the Nottingham Health Profile (NHP) both preoperatively and postoperatively.19–21 This scale consists of eight items on the presence of pain with answering options ‘yes’ and ‘no’. Each positively answered item was summed up to a score ranging from 0 to 8, with higher scores indicating more problems with pain. Disabilities To assess the effect of waiting on condition-specific disabilities, we developed a scale consisting of four to five items. The items addressed specific activities with which the disorder could interfere: standing upright for varicose veins (4 items); straining activities for inguinal hernia (5 items) and dietary habits for gallstones (5 items). Respondents were to indicate the level of experienced difficulties on a 4-point Likert-type scale. The answers were summed to a score ranging from 0 to 12 for varicose veins and 0 to 15 for inguinal hernia and gallstones. The items and response categories are shown in Appendix I. Using the same items, we asked the participants after surgery to indicate how long it took before they were able to carry out the 2007 The Authors Journal compilation 2007 Royal Australasian College of Surgeons

Waiting time intervals Throughout the study, we used the definitions of waiting time intervals given here: d Total waiting time: the number of days between the date of registration on the waiting list and the date of surgery (both taken from the hospital administration). d Waited time: the number of days between registration on the waiting list and completion of the preoperative questionnaire. d Time to wait: the number of days between completion of the preoperative questionnaire and the date of surgery. Note: waited time + time to wait = total waiting time. Analysis First, we used descriptive statistics to analyse the participants’ responses to assess the problems experienced during the wait and the perceived results of surgery and the duration of postoperative recovery. When appropriate, differences between preoperative and postoperative results were assessed using t-tests or non-parametric tests, depending on the type of information. Owing to the qualitative differences in the nature of the three disorders and the associated differences in age and sex distributions between the groups, we did not test whether outcomes differed quantitatively between the three disorders. All descriptive analyses were carried out using spss version 12.0.1 for Windows (SPSS, Chicago, IL, USA) with P < 0.05 taken as statistically significant. Second, we carried out multilevel regression analysis of the data to assess the effect of the length of the wait on (i) the symptoms and disabilities experienced during the wait or (ii) on postoperative outcomes while accounting for potential effects arising from differences between the hospitals in which patients were on the waiting list (e.g. in waiting list management or indications for surgery). For the first part of this objective, we assessed whether the time a patient had waited before completing the preoperative questionnaire was associated with the variables given here: the reported number of colic attacks in the past 4 weeks; the scores on the scales for condition-specific disabilities and the scores on the scales for pain and mobility. Concerning these analyses, it was acknowledged that, owing to the cross-sectional design of our study, the implicit prioritization of patients with more severe symptoms (e.g. by individual surgeons) could obscure a possible association between the time patients had waited and the severity of problems. To correct for this obscuring effect, we included the total waiting time as a variable in the analysis. In result, the found effect of the waited time

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on symptoms and disabilities is applicable when the total waiting time remains constant in the regression equation. For the assessment of the correlation between the length of the wait and the postoperative outcomes, regression analyses concerned the variables mentioned here: the postoperative scores for pain and mobility and the scores for postoperative recovery of the condition-specific disabilities. In these analyses, we treated the respondents’ status when completing the preoperative questionnaire as a ‘baseline’ and assessed whether the subsequent time patients had to wait for surgery was associated with worse postoperative outcomes. Accordingly, the correlation between the time a patient had to wait and the postoperative outcomes is applicable given a constant ‘baseline’ status, that is, a constant combination of the preoperative scores and the time patients had waited before completing the preoperative questionnaire. As the distributions of the waiting times were skewed, we applied a logarithmic transformation on these variables to approach normality. For the multilevel linear regression analyses on the preoperative and postoperative scores concerning conditionspecific disabilities, we used a general linear mixed model (procedure Mixed in spss version 12.0.1). As the scores for pain and mobility were highly skewed, we carried out logistic regression analyses for which we categorized the subjects with zero and one or more positively answered items on each scale. For gallstone disease, a proportional odds model was used to analyse the effect of the wait on the preoperatively reported number of colic attacks, with numbers categorized as 0, 1, 2, 3 and >3.22 MLwiN version 2.0 (Centre for Multilevel Modelling, Bristol, UK) was used for the multilevel logistic and proportional odds models.23 In all regression analyses, we corrected for differences in responses related to age and sex and to whether treatment was provided on an inpatient or outpatient basis, when significant. As the number of regression analyses on the dataset was relatively large, we took P < 0.01 as statistically significant. Table 1.

RESULTS The results are grouped in concordance with the three objectives of our study. In line with the main purpose of our study, the comparisons between preoperative and postoperative findings are reported as to indicate the effect of waiting. Findings on measures that were assessed only before or after surgery or that addressed only the effect of waiting are given correspondingly. Each table reports the specific number of patients included in the analysis, the results of which is given in table. Differences between this number of patients and total response numbers for each group are as a result of missing values in one or more variables.

Participants Table 1 shows the number of eligible patients, the response rates and reasons for dropout throughout the study. Preoperative and postoperative questionnaires were completed by, respectively, 176 and 134 patients with varicose veins, 201 and 152 inguinal hernia patients, and 128 and 98 patients with gallstones. Table 2 gives the characteristics of respondents. The respective median waiting times for surgery per disorder were 170, 115 and 111 days. The characteristics of the respondents were similar to those of the patients who did not respond with respect to the distributions of sex and the waited times, but a higher mean age was found among respondents both for varicose veins (52 vs 48 years; t665 = 3.59, P < 0.001) and for inguinal hernia (63 vs 57; t746 = 4.85, P < 0.001). The non-response analysis among a sample of 230 patients from nine hospitals (19–23% per disorder) who did not consent to participation showed the results as given here: 30 (13%) did not consent because they had no problems with being on the waiting list, 19 (8%) because surgery would take place soon and 13 (6%) because they were tired of waiting. Thirty-eight patients (17%) stated they judged the study as not applicable to them as surgery

Eligible patients, response rates and reasons for dropout throughout the study n

Eligible Informed consent Preoperative response (valid) Surgery not in original hospital Postoperative questionnaire not returned Postoperative response (valid)

Varicose veins %† (%)‡

667 270 176 11 31 134

NA 100 65.2 4.1 11.5 49.6

NA NA (100) (6.3) (15.3) (76.1)

n 748 342 201 20 29 152

Inguinal hernia %† (%)‡ NA 100 58.8 5.8 8.5 44.4

n

NA NA (100) (10.0) (11.9) (75.6)

512 207 128 9 21 98

Gallstones %† NA 100 61.8 4.3 10.1 47.3

(%)‡ NA NA (100) (7.0) (10.9) (76.6)

†Percentage of patients giving informed consent. ‡Percentage of patients returning the preoperative questionnaire. NA, not applicable.

Table 2.

Characteristics of patients and their waiting times

Age, mean (SD) Sex, % men Total waiting time in days, median Surgery on inpatient basis (%)

Varicose veins Preoperative Postoperative (n = 176) (n = 134)

Inguinal hernia Preoperative Postoperative (n = 201) (n = 152)

Gallstones Preoperative Postoperative (n = 128) (n = 98)

51.6 (11.9) 31.8 170

62.9 (11.4) 96.5 115

52.6 (14.4) 35.2 111

39.7

52.0 (11.7) 33.6 166 42.9

62.9

63.0 (11.1) 96.1 113 72.8

94.4

52.9 (14.5) 35.7 98 96.9

SD, standard deviation. 2007 The Authors Journal compilation 2007 Royal Australasian College of Surgeons


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had already taken place (elsewhere) or the delay was owed to medical or personal reasons. The remaining 130 (57%) reported miscellaneous reasons not related to being on a waiting list (predominantly: ‘no time’ or ‘forgotten’). The symptoms and disabilities experienced during the wait Table 3 shows the condition-specific symptoms that the patients reported during the wait. The predominant symptom reported by patients with varicose veins was a feeling of heaviness/tension when standing (n = 120, 71%). A minority reported to have no symptoms (n = 25, 15%), whereas pain was reported by 23 patients (14%). In addition, 35 of 170 patients (21%) reported that one or more complications had occurred in the preceding 4 weeks: varicose eczema (n = 20, 11.8%), phlebitis (n = 12, 7.1%), a venous ulcer (n = 4, 2.4%) and haemorrhage (n = 2, 1.2%). A small group of patients with an inguinal hernia reported severe pain (n = 9, 5%) when they would lift 10 kg, whereas 76 patients (41%) stated this activity would produce no symptoms. Forty-six (38%) of the gallstone patients reported to have had no colic attacks in the preceding 4 weeks, whereas 20 patients (16%) reported one or more colics per week. Table 4 shows the scores on the scale for pain from the NHP. In each group, the respondents’ preoperative scores were significantly higher than after surgery, indicating more problems with pain during the wait. The median preoperative scores for varicose veins and gallstones show that during the wait at least 50% of the respondents in these groups reported one or more problems with pain, whereas the median score for inguinal hernia was zero, indicating that problems with pain were reported by 4

At 3 months after surgery, a large majority (86–95%) of patients in each group reported that their condition-specific symptoms were relieved by surgery, completely or to a large extent (Table 6). More than half of the patients in each group (53–62%) stated they were fully recovered from surgery after 1 month, which increased to 86–92% at 3 months (Table 7). The waiting times of the patients who reported full recovery within 3 months were not significantly different from those who did not (z = 21.3, P = 0.19 for varicose veins; z = 20.8, P = 0.42 for inguinal hernia; z = 20.7, P = 0.48 for gallstones). The effect of waiting time In all three groups, multilevel logistic regression analysis did not show that longer waits were associated with a higher probability of reporting problems with pain either during the wait or postoperatively (see Table 4). For gallstones, the multilevel ordered response regression analysis also showed no association between the time spent waiting and the number of reported colic attacks (cumulative odds ratio = 0.997, z = 20.008, Wald v21 , 0:001; P = 1.0). No significant correlation was found between the scores for condition-specific disabilities and the time patients had waited in each group (Table 8). Only for inguinal hernia, a non-significant (P = 0.099) trend towards more disabilities with longer waited times was found. The scores for the swiftness of recovering from specific disabilities after surgery showed no correlation with the time patients had to wait for surgery (Table 9). Similarly, to the condition-specific disabilities, the multilevel regression analyses showed no significant association at the P < 0.01 level between the length of the wait and the preoperative and postoperative scores for generic problems with mobility (see Table 5). Yet, among the group of inguinal hernia patients, longer waits involved a trend towards a higher probability of problems with mobility during the wait and after surgery (Wald v21 ¼ 3:89; P = 0.049 and Wald v21 ¼ 4:14; P = 0.042, respectively).

DISCUSSION % 14.8 11.2 60.4 13.6 41.1 4.9 22.7 26.5 4.9 37.7 22.1 14.8 9.0 5.7 10.7

†Symptoms when standing for 1.5 h. ‡Symptoms when lifting 10 kg. §Number of colic attacks in preceding 4 weeks. 2007 The Authors Journal compilation 2007 Royal Australasian College of Surgeons

The perceived improvement by surgery and the duration of postoperative recovery

Our results provide an insight into the physical effect of waiting for surgery for varicose veins, inguinal hernia and gallstones, as experienced by patients. The overall findings for the three disorders show that waiting generally involves a period of mildly affected physical health, which is significantly improved after surgery. The reported condition-specific symptoms, however, indicate that the consequences of waiting differ between patients. Although many patients report no or mild physical symptoms, symptoms are marked in a small but substantial group. As the perceived severity of symptoms are an important determinant of a patient’s acceptance of waiting, the found diversity in symptoms suggests that the low urgency that is generally assigned to these disorders may not be justified for all patients equally.24 Similar variation in the severity of symptoms or risks of waiting has been reported for patients awaiting cataract surgery,24 prostatectomy,25 orthopaedic surgery25 and cardiac surgery.26 Accordingly, our findings add to the evidence that the prioritization of patients on waiting lists, as issued in several countries, could reduce the overall burden of delays and improve the patients’ acceptance of waiting times.27–30 The clinical appropriateness of this, however, depends on the appraised

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Table 4.

OUDHOFF ET AL.

Preoperative and postoperative scores on the NHP scale for pain and the associations with waiting time Varicose veins Preoperative Postoperative (n = 171) (n = 133)

Mean (SD) Median

1.67 (1.9) 1.0

1.00* (1.8) 0.0

Inguinal hernia Preoperative Postoperative (n = 199) (n = 151) 1.12 (1.7) 0.0

Gallstones Preoperative Postoperative (n = 125/124) (n = 96)

0.75* (1.5) 0.0

1.49 (1.9) 1.0

0.93* (1.6) 0.0

ML logistic regression†

OR

P-value

OR

P-value

OR

P-value

OR

P-value

OR

P-value

OR

P-value

loge (waited time) loge (time to wait) loge (total waiting time)

1.326 NA 0.742

0.33 NA 0.38

0.601 0.833 NA

0.07 0.37 NA

1.507 NA 0.188

0.19 NA 0.12

0.921 1.004 NA

0.70 0.98 NA

0.943 NA 0.930

0.90 NA 0.88

1.083 1.174 NA

0.84 0.48 NA

*Significant difference (P < 0.05) between preoperative and postoperative scores, Wilcoxon signed rank test. †The results of the multilevel regression analysis on the preoperative scores were corrected for age, sex and an inpatient or outpatient basis of surgery if significant. The postoperative scores were also corrected for the preoperative scores. ML, multilevel; NA, not applicable; NHP, Nottingham Health Profile; OR, odds ratio.

Table 5.

Preoperative and postoperative scores on the scale for mobility and the associations with waiting times Varicose veins Preoperative Postoperative (n = 172) (n = 133)

Mean (SD) Median

1.03 (1.2) 1.0

Inguinal hernia Preoperative Postoperative (n = 201) (n = 151)

0.66* (1.1) 0.0

1.0 (1.4) 0.0

ML logistic regression†

OR

P-value

OR

P-value

OR

loge (waited time) loge (time to wait) loge (total waiting time)

1.161 NA 0.805

0.61 NA 0.53

1.070 0.993 NA

0.77 0.96 NA

1.859 NA 0.446

Gallstones Preoperative Postoperative (n = 127) (n = 97)

0.65* (1.1) 0.0 P-value 0.049 NA 0.023

0.90 (1.5) 0.0

0.66 (1.1) 0.0

OR

P-value

OR

P-value

OR

P-value

0.878 1.422 NA

0.57 0.042 NA

2.855 NA 0.373

0.061 NA 0.097

1.534 0.987 NA

0.31 0.96 NA

*Significant difference (P < 0.05) between preoperative and postoperative scores, Wilcoxon signed rank test. †The results of the multilevel regression analysis on the preoperative scores were corrected for age, sex and an inpatient or outpatient basis of surgery if significant. The postoperative scores were additionally corrected for the preoperative scores. ML, multilevel; NA, not applicable; OR, odds ratio.

Table 6. Patients (%) reporting the degree to which the symptoms were relieved by surgery

Completely Almost completely To a large extent Hardly Not at all

Varicose veins (n = 132)

Inguinal hernia (n = 149)

Gallstones (n = 95)

13.6 32.6 40.2 8.3 5.3

58.4 25.5 9.4 4.0 2.7

47.4 29.5 17.9 3.2 2.1

mismatch between current waiting times and the waiting times that are deemed acceptable for the different patients. Although surgery involved improvements in health for most patients in our study, 9–14% of patients report that symptoms were not relieved by surgery or that they had not recovered from surgery within 3 months. These percentages reflect the rates of surgical complications for these disorders and recurrences of varicose veins or inguinal hernia in published works.31–33 Obviously, the risk of unfavourable outcomes should be discussed with each patient when a decision for surgery is to be made. It may, however, be particularly relevant for patients with minimal or mild physical symptoms. For them, the combined prospect of a long wait and the possibility of disappointing outcomes could outweigh the appraised benefits of surgery and give reason to decide against surgery. We found no significant effect of the length of the wait either on the symptoms or disabilities during the wait or on postoperative

outcomes. Only in patients with inguinal hernia, the associations between longer waiting times and more severe disabilities approached statistical significance more than once. This may suggest that gradual progression of the condition could occur in some patients, but this was either slow or counterbalanced by symptomatic improvement in others. Overall, the findings, however, indicate that for most patients, waiting for elective general surgery primarily involves a prolonged period of symptomatic suffering. Studies addressing the consequences of waiting times in other specialties, that is, orthopaedic and cataract surgery, have found some deterioration of condition-specific measures during the wait.9,34,35 This deterioration might indicate that the natural courses of these conditions involve slightly quicker deterioration than the ones in our study, yet the difference with our findings might also be because of a closer prospective surveillance of Table 7. Patients’ (%) responses on the time it took to fully recover from surgery Varicose veins Inguinal hernia Gallstones (n = 132) (n = 149) (n = 97) 1 week 2 weeks 1 month 2 months 3 months Not fully recovered

9.1 21.2 22.7 24.2 9.1 13.6

9.4 21.5 28.9 22.1 9.4 8.7

8.2 20.6 33.0 22.7 5.2 10.3

2007 The Authors Journal compilation 2007 Royal Australasian College of Surgeons


Table 8.

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Effect of waiting on the preoperative scores for the degree of condition-specific disabilities

Mean (SD) Range



Gallstones (n = 120)

5.46 (3.0) 0–12

4.64 (3.7) 0–15

5.41 (4.1) 0–15

ML linear regression†

b

P-value

b

P-value

b

P-value

loge (waited time) loge (total waiting time)

0.08 20.18

0.83 0.68

0.88 21.69

0.099 0.004

20.82 0.60

0.36 0.52

†The results of the multilevel regression analysis were corrected for age, sex and an inpatient or outpatient basis of surgery if significant. b, regression coefficient; ML, multilevel.

Table 9.

Effect of waiting on the scores for the swiftness of postoperative recovery of condition-specific disabilities

Mean (SD) Range ML linear regression† loge (time to wait) loge (waited time)



Gallstones (n = 91)

11.56 (5.06) 0–20

11.14 (4.28) 0–25

8.83 (5.79) 0–25

b

P-value

b

P-value

b

P-value

0.18 0.32

0.54 0.45

20.06 0.53

0.82 0.16

0.34 0.002

0.37 0.99

†The results of the multilevel regression analysis were corrected for age, sex and an inpatient or outpatient basis of surgery and the preoperative scores for condition-specific disabilities, if significant. b, regression coefficient; ML, multilevel.

patients in these studies that made them more sensitive to observe deterioration in individuals. As in our study, a direct effect of longer waits on worse post-surgical outcomes was not established. In addition to the possibility of gradual deterioration of symptoms, it is of note that waiting for treatment of inguinal hernia or gallstones involves the additional risk of acute complications that require emergency treatment. Current published works in this respect show that this risk applies especially to patients waiting for cholecystectomy. Although reports show different frequencies,13–18 emergency admission rates of up to 0.9 per 100 waiting patients per week are reported,13 whereas complications could occur even more frequently in patients with a previous history of complicated gallstone disease.14,15 Studies on the risk of strangulation of inguinal hernia show annual rates of up to 5–6%18,36–38 but report that most patients who showed with strangulated hernias are not on waiting lists,32–34 partly because strangulation occurred soon after the onset of hernias. These findings combined with our results suggest that the physical effect of waiting will mostly be indicated by the severity of the symptoms that patients present with and the clear presence of risk factors for the development of complications. It therefore seems important to assess this effect at first consultation and treat patients within waiting times that are correspondingly acceptable.

of waiting on these problems. Owing to the design of our study, the results from the regression analysis leave it indistinct whether the wait involved symptomatic progression in individual patients. Implications Waiting lists for elective procedures are an inextricable part of current clinical practice in general surgery. The consequences of waiting should therefore be taken into account when decisions for surgery are to be made. Our findings indicate that the symptoms at presentation are an important determinant of the physical effect of waiting for elective surgery. As this effect differs between patients, it seems logical to prioritize them correspondingly to diminish the overall burden of waiting. Although it seems more necessary to secure timely treatment for patients with marked symptoms or at risk for complications, patients with minimal symptoms may be given the option to abandon a long wait for surgery as its associated risks may not outweigh the appraised benefit. Future research needs to address which waiting time thresholds are deemed appropriate for the different patients to evaluate the acceptability of current waiting times.

REFERENCES Limitations Although the number of participants in each group is sufficient for the objectives of our study, the response rates are disappointing. However, the results of the non-response analysis do not indicate that reluctance to participate was confined to a group with a specific opinion about being on a waiting list. As most characteristics of the participants were also similar to those of who choose not to participate, we assume that the sample can be taken as representative for the patients on waiting lists for the studied disorders. We used a cross-sectional design to provide a relevant insight into the physical problems among patients on waiting lists. Accordingly, we used regression analyses to indirectly estimate the effect 2007 The Authors Journal compilation 2007 Royal Australasian College of Surgeons

1. DeCoster C, Carriere KC, Peterson S, Walld R, Macwilliam L. Waiting times for surgical procedures. Med. Care 1999; 37 (Suppl.): JS187–205. 2. The Standards Sub-Committee of the Victorian State Committee of the Royal Australian College of Surgeons. Surgical waiting lists in Victorian hospitals. Med. J. Aust. 1991; 154: 326–8. 3. Olson DW, de Gara CJ. How long do patients wait for elective general surgery? Can. J. Surg. 2002; 45: 31–3. 4. Nienoord-Bure´ CD, Talma HF. [Waiting lists for medical care in hospitals. Results November 2001]. Utrecht: Prismant, 2002. (In Dutch.) 5. Koomen EM, Hutten BA, Kelder JC, Redekop WK, Tijssen JG, Kingma JH. Morbidity and mortality in patients waiting for

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6.

7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.

22. 23. 24. 25. 26.

27.

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coronary artery bypass surgery. Eur. J. Cardiothorac. Surg. 2001; 19: 260–65. Morgan CD, Sykora K, Naylor CD. Analysis of deaths while waiting for cardiac surgery among 29,293 consecutive patients in Ontario, Canada. The Steering Committee of the Cardiac Care Network of Ontario. Heart 1998; 79: 345–9. Sampalis J, Boukas S, Liberman M, Reid T, Dupuis G. Impact of waiting time on the quality of life of patients awaiting coronary artery bypass grafting. CMAJ 2001; 165: 429–33. Hajat S, Fitzpatrick R, Morris R et al. Does waiting for total hip replacement matter? Prospective cohort study. J. Health Serv. Res. Policy 2002; 7: 19–25. Ostendorf M, Buskens E, van Stel H et al. Waiting for total hip arthroplasty: avoidable loss in quality time and preventable deterioration. J. Arthroplasty 2004; 19: 302–9. Oudhoff JP, Timmermans DR, Bijnen AB, Van der Wal G. Waiting for elective general surgery: physical, psychological and social consequences. ANZ J. Surg. 2004; 74: 361–7. Sarin S, Sheilds DA, Farrah J, Scurr JH, Coleridge-Smith PD. Does venous function deteriorate in patients waiting for varicose vein surgery? J. R. Soc. Med. 1993; 86: 21–3. Davies AH, Mountfield J, Armstrong CP. Inguinal hernia waiting lists: medical and financial implications. Bristol Med. Chir. J. 1989; 104: 106. Sobolev B, Mercer D, Brown P, Fitzgerald M, Jalink D, Shaw R. Risk of emergency admission while awaiting elective cholecystectomy. CMAJ 2003; 169: 662–5. Thornton DJ, Robertson A, Alexander DJ. Patients awaiting laparoscopic cholecystectomy – can preoperative complications be predicted. Ann. R. Coll. Surg. Engl. 2004; 86: 87–90. Cheruvu CV, Eyre-Brook IA. Consequences of prolonged wait before gallbladder surgery. Ann. R. Coll. Surg. Engl. 2002; 84: 20–22. Rutledge D, Jones D, Rege R. Consequences of delay in surgical treatment of biliary disease. Am. J. Surg. 2000; 180: 466–9. Somasekar K, Shankar PJ, Foster ME, Lewis MH. Costs of waiting for gall bladder surgery. Postgrad. Med. J. 2002; 78: 668–70. Riet M van ’t, Burger JWA, Kazemier G, Sambeek M van, Bonjer HJ. [A medical view on waiting lists.] Medisch Contact 2000; 55: 383–6. (In Dutch.) Hunt SM, McEwen J, McKenna SP. Measuring Health Status. London: Croom Helm, 1986. Erdman RAM, Passchier J, Kooijman M, Stronks DL. The Dutch version of the Nottingham Health Profile: investigation of psychometric aspects. Psychol. Rep. 1993; 72: 1027–1035. Van der Zee KI, Sanderman R, Heyink J. A comparison of two multidimensional measures of health status: The Nottingham Health Profile and the RAND 36item Health Survey 1.0. Qual. Life Res. 1996; 5: 165–74. McCullagh P. Regression models for ordinal data (with discussion). J. R. Stat. Soc. Ser. B 1980; 42: 109–42. Rasbach J, Steele F, Browne W, Prosser B. A user’s guide to MLwiN version 2.0. London: Centre for Multilevel Modelling, Institute of Education, University of London, 2003. Dunn E, Black C, Alonso J, Norregaard JC, Anderson GF. Patients’ acceptance of waiting for cataract surgery: what makes a wait too long? Soc. Sci. Med. 1997; 44: 1603–610. Derrett S, Paul C, Morris JM. Waiting for elective surgery: effects on health-related quality of life. Int. J. Qual. Health Care 1999; 11: 47–57. Naylor CD, Sykora K, Jaglal SB, Jefferson S. Waiting for coronary artery bypass surgery: population-based study of 8517 consecutive patients in Ontario, Canada. The Steering Committee of the Adult Cardiac Care Network of Ontario. Lancet 1995; 346: 1605–609. Health Policy and Economic Research Unit, British Medical Association. Waiting list prioritisation scoring systems: a discussion paper. London: British Medical Association, 1998.

28. Hadorn DC, Holmes AC. The New Zealand priority criteria project. Part 1: Overview. Br. Med. J. 1997; 314: 131–4. 29. Taylor MC, Hadorn DC.; the Steering Committee of the Western Canada Waiting List Project. Developing priority criteria for general surgery: results from the Western Canada Waiting List Project. Can. J. Surg. 2002; 45: 351–7. 30. Dennett ER, Kipping RR, Parry B, Windsor J. Priority access criteria for elective cholecystectomy: a comparison of three scoring methods. N. Z. Med. J. 1998; 111: 231–3. 31. London NJM, Nash R. ABC of arterial and venous disease. Varicose veins. Br. Med. J. 2000; 320: 1391–4. 32. Kumar S, Wilson RG, Nixon SJ, Macintyre IM. Chronic pain after laparoscopic and open mesh repair of groin hernia. Br. J. Surg. 2002; 89: 1476–9. 33. Bateson MC. Gallbladder disease. Br. Med. J. 1999; 318: 1745–8. 34. Mahon JL, Bourne RB, Rorabeck CH, Feeny DH, Stitt L, Webster-Bogaert S. Health-related quality of life and mobility of patients awaiting elective total hip arthroplasty: a prospective study. CMAJ 2002; 167: 1115–21. 35. Leinonen J, Laatikainen L. The decrease of visual acuity in cataract patients waiting for surgery. Acta Ophthalmol. Scand. 1999; 77: 681–4. 36. Gallegos NC, Dawson J, Jarvis M, Hobsley M. Risk of strangulation in groin hernias. Br. J. Surg. 1991; 78: 1171–3. 37. Rai S, Chandra SS, Smile SR. A study of the risk of strangulation and obstruction in groin hernias. Aust. N. Z. J. Surg. 1998; 68: 650–54. 38. Mcentee GP, O’Carroll A, Mooney B, Egan TJ, Delaney PV. Timing of strangulation in adult hernias. Br. J. Surg. 1989; 76: 725–6.

APPENDIX I Items and response categories of the scales for condition-specific disabilities Items Varicose veins (Cronbach’s a = 0.92 and 0.93 preoperative and postoperative, respectively) Stand for 15 min waiting for a bus Stand for an hour on the train Stand for 2 h listening to a concert Attend a stand-up reception for 3 h Inguinal hernia (Cronbach’s a = 0.91 and 0.88 preoperative and postoperative, respectively) Have a fit of coughing Put a bag of potatoes (5 kg) from the floor on to the dresser Put a bucket of water from the floor on to a step stool Put a moving box filled with books (25 kg) from the floor on to a table Lift up a 6-year-old child Gallstones (Cronbach’s a = 0.84 and 0.87 preoperatively and postoperatively, respectively) Eat a bar of chocolate (50 g) Drink three glasses of wine Eat an ample serving of French fries with mayonnaise Eat two new herring or steamed mackerel Eat a butter and cheese sandwich Response categories Preoperative question: ‘Is it possible for you to .’.: Response categories: with no problems/with some inconvenience/with marked symptoms/impossible Postoperative question: ‘At which time after surgery was it trouble free possible for you to.?’ Response categories: £1 day/after 1 week/after 1 month/after 2 months/after 3 months/still not possible 2007 The Authors Journal compilation 2007 Royal Australasian College of Surgeons