Urgency and priority for cardiac surgery: a clinical judgment analysis

The Clinical Standards Advisory Group has expressed concern over the lack of clear criteria with which to accord priority to patients awaiting coronary artery bypass surgery.1 Until recently, the most notable research on what determines “urgency” was to be found in reports from Ontario which point to variations between doctors and institutions in the criteria they use to place patients in a queue.2-4 Earlier this year the New Zealand National Advisory Committee on Health published its findings on the impact that some social factors, such as the threat to independence, the care of dependants, or the patient's ability to work, might have on decisions related to priority.5 The influence of demographic or lifestyle factors, such as age or smoking habit, on waiting list priority has been debated prominently in the United Kingdom. 6 7 Doctors may take an individual view of the probable effectiveness of revascularisation in some patients (for example, smokers compared with non-smokers). However, neither the perceived efficacy of the procedure nor the distinction between “urgency” (the speed required to intervene to obtain a desired clinical outcome) and “priority” (the relative position on a surgical waiting list) has yet been investigated. Doctors might agree that a patient who smokes needs urgent intervention but disagree over the priority this patient should be accorded on a waiting list for surgery. In response to the Clinical Standards Advisory Group report, a regional workshop sponsored by the Northern Ireland Clinical Resource Efficiency Support Team was convened in the spring of 1996 to address these issues. Two main research questions were: • • Do clinicians pay attention to demographic and lifestyle factors when making urgency and priority judgments? • • Do disagreements between clinicians arise out of differences in how they attend to clinical and demographic factors in arriving at …