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Psychosomatic Medicine 66:251-257 (2004)
© 2004 American Psychosomatic Society

ORIGINAL ARTICLES

Patient Psychological Characteristics Have Minimal Influence on Surgical Prioritization

Nick Glozier, MA, MSc, MRCPsych, Graeme Groom, MA, FRCS and Martin Prince, MD, MRCPsych

From the Institute of Psychiatry, London; and Kings College Hospital, London, UK.

Address correspondence to Dr. Nick Glozier, Institute of Psychiatry, Box 060, De Crespigny Park, London SE5 8AF, UK. E-mail: n.glozier{at}iop kcl.ac.uk


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
OBJECTIVE: Rationing of health care is universal in systems free at the point of delivery. United Kingdom National Health Service (NHS) policy is for treatment on the basis of "clinical need." Surgeons routinely prioritize elective cases, and structured assessments of symptom severity have been suggested as a rational method of prioritization. We hypothesized that patient psychological factors would play an important role in prioritization as currently practiced.

METHODS: Two hundred thirty participants were recruited from a potential pool of 259 eligible referrals to an orthopaedic department for assessment of lower limb arthroplasty. Participants were assessed at time of referral and followed for 2.5 years. Associations were estimated between participant’s psychological distress, illness perceptions, and the outcome of surgical prioritization.

RESULTS: One hundred forty-one participants were listed for arthroplasty; 62 (44%) of these were considered urgent cases. Pain was the only univariate predictor of this outcome. Patient’s psychological distress and illness perceptions were not associated with being classified as urgent even after adjusting for clinical and demographic status. In a multivariate model, only older age showed an independent effect (OR 2.75, 95% CI 1.14, 6.66) of increasing the chances of being considered urgent. Urgent cases had a 3-month-shorter inpatient wait among the 108 participants operated on during the study.

CONCLUSIONS: The psychological status of arthroplasty candidates had no significant effect on the surgical prioritization process. Allocation to the urgent list appears to be based primarily on the patient’s age, but is partially influenced by patient’s better physical health and viewing treatment as being effective.

Key Words: arthroplasty, • illness perceptions, • priority, • waiting lists, • psychiatric disorder.

Abbreviations: MCS = mental component score;; PCS = physical component score;; GHQ-12 = general health questionnaire;; IPQ-R = illness perception questionnaire-revised;; HRQOL = health related quality of life.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
A recent United Kingdom National Audit Office report (1) suggested that political imperatives may have trumped clinician-determined need in the ordering of priorities for the delivery of surgical care. In their response to the report, government ministers highlighted the need to cut waiting lists but reiterated that those in most clinical need should be treated first. For elective surgery in the United Kingdom, as in many other capacity-limited health care systems, it is common to prioritize patients into "urgent" and "routine" cases. This prioritization is a major determinant of the length of time an individual spends on the inpatient waiting list for an operation (2,3). Despite the political importance attached to it, a longer inpatient waiting time has not been shown to be consistently associated with clinical deterioration. A prospective study in Australia failed to demonstrate any effect (4), although in Canada waits longer than 6 months were associated with decline (5). In the UK ENTRHO study (6), being on the inpatient waiting list for longer than 12 months was associated with worse postoperative outcome, independent of the time spent on the outpatient list.

The process of clinical prioritization has itself received less attention. Scoring systems have been developed to standardize the process in New Zealand and Canada (7,8) and are endorsed by the British Medical Association (9). For elective lower limb arthroplasty, these reflect the major symptoms of the diseases leading to the need for surgery: pain and limited mobility (10,11). Yet a systematic review of the Medline and PsychInfo databases using the following medical subject headings (MeSH) terms (waiting, priorit$, decision making, surgery, hip replacement, knee replacement, arthroplasty) revealed no published attempts to ascertain the determinants of prioritization in clinical practice. The National Health Service (NHS) characterizes clinical need as the "ability to benefit" (12), and those with the most pain and the least mobility may not benefit the most from an arthroplasty (13). Co-morbidity, both physical and psychiatric, may alter the ability to benefit (14,15). Personality traits (16), patient preferences (17,18), and illness cognitions (19) may affect both willingness to undergo surgery and ability to benefit from it.

Rational prioritization may be traduced by unjustifiable discriminatory practices (20). An allied concern is that patients (and referrers, and surgeons) will "game" the system and exaggerate their claims for urgency (21). This may be determined by patients’ psychological characteristics and social resources. Although patients’ views on who should be prioritized generally concord with those of professionals, patients on waiting lists think that those actually prioritized are older, more likely to complain and be "foreign" (22). Earlier research has also identified a lack of correlation between structured priority scores and both the surgeon’s assessment (23) and the time to operative intervention (24). A Dutch study concluded that age, gender, occupation, and education had no effect on prioritization. A search of Medline and PsychInfo using the MeSH terms above in combinations with "depress$, personality, illness perceptions/cognitions/attitudes, social class, SES" found no studies that examined whether patients’ psychological characteristics influence surgical prioritization.

In this empirical study, we sought to identify the factors that, in practice, influence orthopaedic surgeons’ prioritization. Specifically, the primary hypothesis was that patient psychological distress would be an independent predictor of being considered an urgent case, adjusting for potentially confounding clinical and demographic variables. The secondary hypothesis was that patients’ illness perceptions of potential treatment effectiveness in symptom relief would also be a significant predictor of this outcome.

Power Calculation
In reality, any difference in prioritization, with its resulting effect on inpatient waiting times and quality of life, would be clinically important. This paper is a subset of a larger ongoing study examining the influence of psychological factors on health care processes and outcomes. One hundred forty-one patients were placed on the inpatient waiting list, and 62 (44%) were prioritized. The "exposure" was psychological distress, defined as a GHQ-12 score of greater than 5, which had 55% prevalence. Using the statcalc package, with a statistical confidence of 95% and a power of 0.80, this study was able to detect a relative risk of being considered urgent of 1.7 in the most psychologically distressed (OR 2.3).


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
This was a naturalistic cohort study of consecutive referrals to the Department of Orthopaedics at King’s College Hospital, which has 7 consultant surgeons. All referral letters received from August 1999 to April 2000 were screened. Patients were included as potential participants if they were more than 50 years old and the referral described chronic symptoms of arthritis (joint pain, stiffness, and reduced mobility), or the referring doctor directly referred to the need for lower limb total joint replacement. Those with acute injuries or who needed revision operations were excluded. The study was passed by the 2 ethics committees of the Institute of Psychiatry and King’s College Hospital.

All participants were first approached by letter, followed up with a telephone call inviting them to take part. If agreeable, they were interviewed, almost always at home, within 1 month of the department receiving a referral letter and in every case before the initial outpatient appointment. Informed consent concerning the aims of the study was obtained from each participant. Those with clinical signs of cognitive impairment (Mini-Mental State score < 23) were excluded at this stage.

Assessments
Participants were interviewed for information regarding sociodemographic status. They self-completed questionnaires concerning health status, joint impairment, psychological distress, personality, social support, and illness perceptions.

Predictor Measures
Psychological Factors
Psychological Distress Twelve-Item General Health Questionnaire (GHQ-12) (25)
The GHQ-12 was developed as a screening tool for psychiatric disorder and was commonly used to determine thresholds for 2-stage epidemiological surveys. It has assumed several forms over the years and has been subject to numerous reliability and validity studies in varied clinical populations.

The 12-item self-report scale measures common symptoms of depression and anxiety. Scored 0 to 0–1 to 1, it produces a total score of 0 to 12 and has scores in different populations at which point an individual would be considered a "case." In primary care, the subject is usually considered a case with a score of more than 3. However, at this threshold, 58% of chronically ill or disabled people are considered cases, and recently a threshold score of 6 has been suggested as better in hospital inpatients (26).

Illness Perceptions of Treatment Effectiveness
A number of potential models of health beliefs exist, although most attempt to explain health-promoting, rather than illness, behavior. Leventhal’s self-regulatory model refers to the "mental activity undertaken by an individual who believes him or herself to be ill" (27). Based on this, an earlier study showed that certain illness perceptions predicted functional and psychological outcomes after arthroplasty (19). The Illness Perception Questionnaire Revised (IPQ-R) (28) is a 7-subscale self-report questionnaire that assesses cognitive representations of illness. Some of these subscales are concerned with areas such as illness causation. Only the subscales identifying perceptions of treatment effectiveness in symptom control and likely consequences of the arthritis were used because they may reflect the patient’s views about the relative benefits of treatment and thus influence clinical decisions. High scores reflect greater perceptions of treatment symptom control (effectiveness).

Clinical Status
These measures capture most of the indices of clinical severity suggested to form the basis of rational prioritization systems (10), as follows.

Health Status Medical Outcome Study SF-12 (29)
This widely used 12-item self-report measure of health generates scaled summary scores for physical (PCS) and mental health (MCS) ranging from 0 to 100, with higher scores indicating better health. These scores are comparable to those obtained from the SF36, which are known to be responsive to clinical change after arthroplasty (30).

Pain
The 5-point question on pain from the SF-12 was used.

Joint Impairment Oxford Hip Score (31)
A self-report instrument assessing pain and function related to hip impairment, adapted for use with both hip and knee impairment. It is highly responsive to the effect of hip arthroplasty (31), and in pilot work it had equivalent concurrent validity with the SF-36 physical function and pain scores as a measure of severity in those requiring hip or knee replacement (data available from author on request).

Data on co-morbidity (number of other chronic illness diagnoses) (32), current medication, previous arthroplasty, and number of joints requiring surgery were all collected.

Sociodemographic Factors
Age, gender, social class (from the Registrar General’s classification of occupations), income, and ethnicity (country of birth) were assessed. These have all been posited as potential biases in prioritization (3,22) and may confound any finding.

Outcome
The dichotomous outcome was the prioritization decision by the assessing surgeon to place the participant on either the "urgent" or the "routine" waiting list. Participants were included if they were placed on the list for arthroplasty at any of their first 3 attendances at outpatient clinic with no other intervention, for example, arthroscopy.

Analysis
Univariate analyses were carried out to investigate associations between characteristics of the 141 participants on the arthroplasty waiting list and the outcome of the surgeon’s prioritization. For all categorical variables, proportions of patients classified as urgent or routine were compared using the chi-square test statistic or {chi}2 test for trend, as appropriate. For continuous variables, a comparison of the means between those placed on the "urgent" and "routine" waiting lists was conducted using an unpaired t test. All variables were approximately normally distributed.

Differences in the 7 surgeon’s propensity to prioritize were examined by a {chi}2 test.

The principal hypothesis was then tested by further examining any association of psychological distress with inpatient waiting list prioritization, with stratified analysis and logistic regression. The association was initially stratified by potential confounders: gender, age, pain, functioning, and impairment. Continuous measures were dichotomized for this stratification and further logistic regression. The first logistic regression model included only the psychological characteristic as an explanatory variable. The second model included all the variables from the stratified analysis. A third model included an interaction term if this was suggested by the stratified analysis based on the test of homogeneity of the stratified odds ratios.

This was repeated for the secondary hypothesis.

Then a multivariable logistical regression model was constructed using univariate predictors (p < .10 or OR > 2.0/< 0.5) age, gender, hypothesized predictors, and those from previous studies, and adjusting for surgeon as a categorical variable. A series of backwards stepwise logistic regression models, removing variables on the basis of likelihood ratio tests, was conducted to produce a parsimonious model of the predictors of being classified as an urgent case.

Missing data were assumed to occur at random: there were no associations with age or gender. The analysis was carried out using the STATA statistical software package.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
There were 259 eligible referrals contacted by letter and phone. Eight were excluded because of lack of English, 2 because of diagnosed dementia, 4 were too ill to be interviewed, and 15 refused. Two hundred thirty participants consented to take part. Age, gender, and ethnic origin for the nonparticipants was similar to that of the participants. One hundred forty-one (61%) of these participants were placed on the waiting list for lower limb arthroplasty in the first 3 outpatient appointments, over the subsequent year, without intervention. Those who did not attain this outcome were either deemed not to require arthroplasty by the surgeon (51 patients), to require arthroscopy instead (21 patients), were considered too frail for surgery (7 patients), died between referral and appointment (3 patients), did not attend their appointments (5 patients), or opted for private treatment (2 patients). Of the 141 placed on the waiting list, 62 (44%) were considered urgent cases. There were no primary arthroplasty candidates referred during this period who were not detected by the eligibility criteria.

Of all the characteristics assessed, only the pain score differentiated between those prioritized and those considered routine (Tables 1 and 2 Go). There was a tendency for those presenting for hip replacements to be more likely to be prioritized than knee replacements candidates (OR 1.89, 95% CI 0.95, 3.76).


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  		TABLE 1. Associations of Continuous Baseline Variables With Prioritization Comparing Means With Independent Sample Student’s t Tests
 

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  		TABLE 2. Univariate Associations of Categorical Characteristics With Surgical Priority, Compared With Odds Ratios (OR) (Some Missing Data Points, Assumed at Random)
 
There was no apparent difference in the propensity of surgeons to assign urgency ({chi}2 8.16, df 6, p = .23), although power was somewhat limited.

Effect of Psychological Distress
Of the participants listed for arthroplasty, 134 completed the GHQ-12. Seventy-one (53%) were considered cases ("psychological distress") at the 5/6 threshold. There was no association of psychological distress with being "urgent" (OR 1.60, 95% CI: 0.81, 3.31). There was no effect stratifying for postulated confounders (age, gender, clinical status). Simultaneous adjustment using multivariable logistic regression modeling reduced the level of association (OR 1.45, 95% CI: 0.60, 3.50) (Table 3).


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  		TABLE 3. Association of Psychological Distress (GHQ score >5) With Being Classified as an Urgent vs. Routine Case, Stratified by Potential Confounders (Data Available for 57 Routine Cases and 77 Routine Cases)
 
Among those requiring a knee replacement, there was a nonsignificant tendency to be considered an urgent case if the patient was experiencing psychological distress (OR 3.05, 95% CI: 0.99, 9.37).

Effect of Perceptions of Treatment Effectiveness
Dichotomizing this continuous scale revealed no association between patient perceptions of treatment effectiveness and being "urgent" (OR 1.21, 95% CI: 0.58, 2.53). Stratification showed no evidence of confounding, but there was deviation from the assumption of proportional odds in the stratification of age (p = .06) (Table 4).


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  		TABLE 4. Association of Perceptions of Treatment Effectiveness (High vs. Low) With Being Classified as an Urgent vs. Routine Case, Stratified by Potential Confounders (Data Available for 48 Urgent Cases and 72 Routine Cases)
 
In the multivariable analysis, there were no significant effects. There was no observable interaction with age (likelihood ratio test p = .11 for removal of the interaction term).

Determinants of Surgical Classification as "Urgent"
Modeling a parsimonious set of predictors of prioritization (adjusting for surgeon) produced 3 determinants of being urgent: Older age showed an independent effect (OR 2.75, 95% CI: 1.14, 6.66), while perceptions of the treatment being more effective (OR 1.86, 95% CI: 0.77, 4.50) and having a better physical health status (OR 1.32, 95% CI: 0.56, 3.10) were important but nonindependent predictors.

Inpatient Waiting Time
Of the 141 participants placed on the inpatient waiting list, 108 had received an arthroplasty within 2 years. The inpatient waiting time is conventionally the time from being placed on the waiting list to undergoing arthroplasty. However, a number of factors can intervene, for example, suspension for illness, or cancellation for bed shortages. The inpatient waiting time was calculated as the number of months on the inpatient list excluding these interruptions. Thirty-three of the 108 arthroplasties for which there was data experienced a delay after being prioritized and before receiving the arthroplasty: 13 for health-related reasons, 14 from hospital cancellations, and 6 because of personal reasons. Removing the period delayed for each participant, the mean inpatient waiting time was 8.0 months (SD 5.0). For comparison, the mean inpatient waiting time including the delays for was 8.9 months (SD 5.4). The data were not skewed (skewness stat 0.58, SE 2.4) (Figure 1).



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  		Figure 1. Comparison of inpatient waiting times (adjusted and unadjusted for delays) between urgent (n=52) and routine (n=56) patients.

 
Of these 108 participants, urgent cases waited only 6.6 months (SD 4.6) compared with an average of 9.7 (SD 5.1) months in routine patients, a highly significant difference of 3.1 months (95% CI; 1.2, 5.1). This differential was very similar in the inpatient waiting time including the period of delay (7.4 vs. 10.7 months) (Figure 1).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
ACKNOWLEDGMENTS
 REFERENCES
 
Among these candidates for lower limb arthroplasty, psychological distress was commonplace (53%). This is similar to the 56% prevalence in a previous study using the GHQ in this population type (33). Psychological factors, in the form of psychological distress and perceptions of treatment effectiveness, did not have major influences on the outcome of surgical prioritization. However, there were effects in certain subgroups. In candidates for knee arthroplasty, greater psychological distress increased the likelihood of being considered urgent (OR 3.05, 95% CI 0.99, 9.37), whereas among the younger group perceptions of greater treatment effectiveness were strongly but nonsignificantly (OR 2.74, 95% CI 0.85, 8.89) associated with being urgent. The first of these is difficult to account for because there is no a priori reason why distress should influence the surgeon’s prioritization of knee and not hip patients and may reflect a type 2 error. Illness perceptions of effectiveness may present as desire for treatment, which might influence surgeons, who would not otherwise consider younger patients as urgent cases.

The overall lack of association of social and psychological factors supports the rational approach to prioritization for elective surgery. Surgeons did not differ greatly in their likelihood to prioritize, and one might assume that they were basing their decisions on important morbidity variables. In contrast, the final model demonstrated that there were no strong clinical predictors of the outcome of prioritization.

There have been no other studies of influences on prioritization. In this study, urgent cases waited 3 months less for their operation. Inpatient waiting time has been shown previously to be associated with the outcome of prioritization in the UK (2) and Holland (3). Other studies have analyzed factors associated with longer and shorter inpatient waiting times. Of 114 patients in a Canadian study, patients with shorter waits (<6 months) had a poorer HRQOL and less mobility at time of referral (5). Other Canadian studies have shown that pain and physical function were not associated with length of wait (34,35). Gender, age, and socioeconomic status also appear to have no effect (3,34). Marital status, language, increased body mass index, pain medication use, and surgeon all had independent effects but explained little (<10%) of the variance (34).

The length of wait does seem to have a detrimental effect. Longer inpatient waits are associated cross-sectionally with greater preoperative impairment (6). Longitudinal cohort studies have shown that those who wait longer show more preoperative functional decline after referral (5), although the effect may be small (4), and experience less health gain from the operation (5,6).

What is going on? It may be that the validated measures of clinical and psychological status used here do not capture the complex interplay in the consultation. Discussion with the surgeons involved suggested that they prioritize according to experience and clinical judgment, rather than structured scoring systems. Different surgeons may be using different personal criteria to prioritize, and this study was not powered to be able to analyze this. This was certainly the case in Canada, where surgeons disagreed on how two thirds of patient characteristics affected their decision to perform a knee replacement (36). The surgeons have different interests: Two of the 7 accounted for half of the knee candidates, and a different 2 for half the knee operations (data not shown but available). If distress influenced prioritization in these 2 in a reverse way to the others, this may account for the interaction between joint type and psychological distress in determining urgency.

At a macro level, differences in patient enthusiasm accounted for variability in arthroplasty rates (37). Other studies have highlighted differences in an individual’s desire for surgery (17,18). These have been based among "potential" candidates. In this study, the participants had already made the decision to consult a surgeon, attended the outpatient appointment, and agreed to surgery. The outcome was whether the surgeon considered them an urgent or routine case. Perceptions of the treatment being more effective were an important, but not statistically significant, influence in the final model.

In the past, the health service has also been accused of "ageism" against the elderly by some charities (20) and against younger people by patients on waiting lists (22). This study provides some support for the latter point of view: the only significant predictor of the outcome of prioritization in a parsimonious adjusted model was being older than 70 years. Previous studies have not found any effect of age on reducing waiting time. In this study, although those in the older age group were more likely to be considered urgent, they were also more likely to experience delays (30% vs. 20%) and as such had a nonsignificant reduced total inpatient waiting time of 8.1 vs. 9.9 months.

This study was limited in that it did not include information from radiographs or clinical examinations (which are not recorded in a systematic format). The surgeons reported that these have only minimal influence on their decisions, and prioritization criteria accord them little importance (10). Preoperative radiographic status is not associated with expressed pain (38) and has an unclear relationship to outcome (38,39). The participants reflect consecutive referrals to a single orthopaedic department and so may not represent the case load of other departments. Furthermore, there might be some clinical change between the study and surgeons’ assessments. Some rapidly deteriorating conditions may have been included in the prioritized group, which would reduce any observed differences. Participants were aware that the study was looking at the whole process of referral and treatment (all of which data were collected from hospital information systems), and so certain participants may have exaggerated their condition. There were, however, no differences on the Lie scale of the Eysenck Personality Questionnaire (data available from author), which is thought to capture this tendency.

This is the first study to assess whether patient psychological characteristics influence the outcome of surgical prioritization. Effects are seen in certain subgroups but have little overall impact. Of the recommended prioritization criteria, pain had a univariate association with this decision, which was explained by other factors. A parsimonious predictive model of being considered urgent yielded only 1 independent association: that of reverse ageism, and this important decision appears somewhat clinically arbitrary. A more in-depth and qualitative evaluation of the actual consultation may be required to understand the process of prioritization, which daily affects how long thousands of patients wait for an arthroplasty.


   ACKNOWLEDGMENTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
REFERENCES
 
During this study Dr. Glozier was supported by a Wellcome Trust Training Fellowship in Health Services Research.

We would like to thank Ray, Jenny and Sharon in orthopaedic administration for their invaluable help and the two anonymous reviewers for their contributions.

Received for publication June 12, 2003.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 

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