Adapting to waiting lists for coronary revascularization. Do Canadian specialists agree on which patients come first?

To assess specialists' adaptation to long waiting lists for coronary revascularization, and their acceptance of a formal queue-ordering schema proposed by an expert panel.

Mail survey of practitioners in referral centers using 49 hypothetical case scenarios. Scenarios were rated for maximum acceptable delay prior to coronary surgery, on a scale with seven interventional time frames graded from emergency to three to six months' permissible delay. The survey included the proposed schema and rating system; respondents were invited to differ as they saw fit. HYPOTHETICAL PATIENTS: Assumed uniformly to be middle aged with typical angina, but clinical factors varied, eg, severity and stability of angina, response to medical therapy, coronary anatomy, and noninvasive test results. PHYSICIAN SUBJECTS: There were 122 respondents, for a 60 percent response rate, including a majority of cardiac surgeons and invasive cardiologists on staff in Ontario teaching hospitals.

Fifty-seven percent rated some scenarios for acceptable waiting times of three to six months; another 39 percent rated their least urgent scenarios to wait six weeks to three months. Interpractitioner agreement was high: for 48/49 scenarios, at least 75 percent of urgency ratings fell within two contiguous points on the scale. Symptom status was the dominant determinant of waiting time, with mean maximum acceptable wait of 74 days for patients with mild-moderate stable angina but three days for those receiving parenteral nitroglycerin (p less than 0.00001). About half the ratings matched those predicted based on the original panel's consensus criteria; 90 percent were within one scale point.

Specialist practitioners in Ontario have adapted to waiting lists for coronary artery bypass surgery/percutaneous transluminal coronary angioplasty, and assess the priority of hypothetical patients in similar ways and in reasonable accord with formal queue-ordering criteria. This behavior may help mitigate the impact of resource constraints, allowing delay of services for those with less acute need--a potential contrast to delayed access in America based on low income or lack of insurance.