Related Experiment Videos
Assigning priority to patients requiring coronary revascularization: consensus principles from a panel of
C D Naylor1, R S Baigrie, B S Goldman
1Clinical Epidemiology Unit, Sunnybrook Health Science Centre, Toronto, Ontario.
Insights
To address long coronary surgery wait times in Canada, experts developed guiding principles for prioritizing patients needing revascularization. Anginal symptoms and ischemic risk are key factors in determining urgency for coronary revascularization.
Area of Science:
- Cardiology
- Cardiac Surgery
- Health Policy
Background:
- Lengthy waiting lists for coronary revascularization in Canada necessitate improved patient prioritization strategies.
- A panel of 16 cardiologists and cardiac surgeons was convened to establish guiding principles for urgent patient referral.
Framework:
- Guiding principles were derived using a case scenario questionnaire rated by panelists on a seven-point urgency scale.
- Consensus was reached on factors influencing revascularization urgency, including symptoms, anatomy, and ischemic risk.
Implementation:
- Panelists rated 438 case scenarios to determine maximum acceptable waiting times for coronary surgery.
- The developed principles provide explicit ranking criteria based on angina class and response to medical therapy.
Implications:
- The principles aim to rationalize patient queues for coronary revascularization, prioritizing based on symptom severity and risk of adverse events.
- These guidelines are intended to support, not cause, treatment delays, fostering more equitable access to timely cardiac care.
Abstract:
In light of lengthy waiting lists for coronary surgery in Canada, a panel of 16 cardiologists and cardiac surgeons was convened to derive guiding principles for ranking how urgently diverse patients with angiographically proven coronary disease require revascularization. Factors likely to affect urgency were agreed upon by the panelists and incorporated into a case scenario questionnaire. Each panelist then rated 438 case scenarios with respect to maximum acceptable waiting time on a scale with seven time frames ranging from emergency surgery ('level 1') to delays of up to six months ('level 7'). The scenario rating process facilitated attainment of a panel consensus. The purpose of the principles is to assist in assigning priorities to patients according to both symptoms and risk of death or additional morbidity from ischemic events. The pattern or severity of the patient's anginal symptoms and the response of those symptoms to medical therapy emerged as the single most important determinant of the level of urgency. Anatomy and noninvasive tests of ischemic risk were the other key determinants of priority. All other factors were less important, and operated largely within a given level of urgency on the seven-point scale. The principles, including explicit ranking criteria divided according to angina class, are outlined in this final report. The panel specifically cautioned that adoption of such principles is not designed to countenance delays in treatment, but if necessary, should help form more rational queues for coronary revascularization.