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Fairness in the coronary angiography queue
D A Alter1, A S Basinski, E A Cohen
1Sunnybrook & Women's College Health Sciences Centre, Ont.
Insights
Waiting times for coronary angiography reflect clinical urgency but are also influenced by physician affiliation. This impacts patient priority and access to care.
Area of Science:
- Cardiology
- Health Services Research
Background:
- Coronary angiography waiting lists often lack explicit criteria, potentially deprioritizing clinically urgent patients.
- Patient priority may not align with clinical acuity due to informal queuing practices.
Purpose of the Study:
- To investigate clinical and nonclinical factors influencing patient waiting times for coronary angiography.
- To assess the impact of physician referral patterns on angiography access.
Main Methods:
- A prospective cohort study followed 357 patients from triage to angiography or adverse event.
- Physician hospital affiliation and a retrospective clinical urgency rating scale were analyzed.
- Waiting times were compared against recommended maximum waiting times (RMWT) across referral groups.
Main Results:
- Clinical factors partially aligned with urgency ratings, showing moderate agreement with actual waiting times (kappa = 0.53).
- Physician affiliation was a significant independent predictor of waiting time (p < 0.001).
- Physician affiliation explained 9.3% of waiting time variation, compared to 45.6% for all clinical factors.
Conclusions:
- Informal coronary angiography queuing systems incorporate clinical acuity but are significantly swayed by nonclinical factors.
- Physician relationships with the catheterization facility influence patient access to timely procedures.
Background:
Since waiting lists for coronary angiography are generally managed without explicit queuing criteria, patients may not receive priority on the basis of clinical acuity. The objective of this study was to examine clinical and nonclinical determinants of the length of time patients wait for coronary angiography.
Methods:
In this single-centre prospective cohort study conducted in the autumn of 1997, 357 consecutive patients were followed from initial triage until a coronary angiography was performed or an adverse cardiac event occurred. The referring physicians' hospital affiliation (physicians at Sunnybrook & Women's College Health Sciences Centre, those who practice at another centre but perform angiography at Sunnybrook and those with no previous association with Sunnybrook) was used to compare processes of care. A clinical urgency rating scale was used to assign a recommended maximum waiting time (RMWT) to each patient retrospectively, but this was not used in the queuing process. RMWTs and actual waiting times for patients in the 3 referral groups were compared; the influence clinical and nonclinical variables had on the actual length of time patients waited for coronary angiography was assessed; and possible predictors of adverse events were examined.
Results:
Of 357 patients referred to Sunnybrook, 22 (6.2%) experienced adverse events while in the queue. Among those who remained, 308 (91.9%) were in need of coronary angiography; 201 (60.0%) of those patients received one within the RMWT. The length of time to angiography was influenced by clinical characteristics similar to those specified on the urgency rating scale, leading to a moderate agreement between actual waiting times and RMWTs (kappa = 0.53). However, physician affiliation was a highly significant (p < 0.001) and independent predictor of waiting time. Whereas 45.6% of the variation in waiting time was explained by all clinical factors combined, 9.3% of the variation was explained by physician affiliation alone.
Interpretation:
Informal queuing practices for coronary angiography do reflect clinical acuity, but they are also influenced by nonclinical factors, such as the nature of the physicians' association with the catheterization facility.