Llewellyn-Thomas H A, Arshinoff R, Bell M, Williams J I, Naylor C D
Clinical Epidemiology Unit, Sunnybrook Health Science Centre, North York, Ontario, Canada.
J Eval Clin Pract. 1998 Feb;4(1):63-74. doi: 10.1046/j.1365-2753.1998.t01-1-00006.x.
We assessed patients on the waiting lists of a purposive sample of orthopaedic surgeons in Ontario, Canada, to determine patients' attitudes towards time waiting for hip or knee replacement. We focused on 148 patients who did not have a definite operative date, obtaining complete information on 124 (84%). Symptom severity was assessed with the Western Ontario/McMaster Osteoarthritis Index and a disease-specific standard gamble was used to elicit patients' overall utility for their arthritic state. Next, in a trade-off task, patients considered a hypothetical choice between a 1-month wait for a surgeon who could provide a 2% risk of post-operative mortality, or a 6-month wait for joint replacement with a 1% risk of post-operative mortality. Waiting times were then shifted systematically until the patient abandoned his/her initial choice, generating a conditional maximal acceptable wait time. Patients were divided in their attitudes, with 57% initially choosing a 6-month wait with a 1% mortality risk. The overall distribution of conditional maximum acceptable wait time scores ranged from 1 to 26 months, with a median of 7 months. Utility values were independently but weakly associated with patients' tolerance of waiting times (adjusted R-square = 0.059, P = 0.004). After splitting the sample along the median into subgroups with a relatively 'low' and 'high' tolerance for waiting, the subgroup with the apparently lower tolerance for waiting reported lower utility scores (z = 2.951; P = 0.004) and shorter times since their surgeon first advised them of the need for surgery (z = 3.014; P = 0.003). These results suggest that, in the establishment and monitoring of a queue management system for quality-of-life-enhancing surgery, patients' own perceptions of their overall symptomatic burden and ability to tolerate delayed relief should be considered along with information derived from clinical judgements and pre-weighted health status instruments.
我们对加拿大安大略省部分骨科医生的目标样本中等待手术的患者进行了评估，以确定患者对髋关节或膝关节置换手术等待时间的态度。我们重点关注了148名尚无明确手术日期的患者，其中124名（84%）提供了完整信息。使用西安大略和麦克马斯特大学骨关节炎指数评估症状严重程度，并采用特定疾病的标准博弈法来得出患者对其关节炎状态的总体效用值。接下来，在一项权衡任务中，患者要在两种假设情况中做出选择：一种是等待1个月接受手术，但术后有2%的死亡风险；另一种是等待6个月进行关节置换手术，术后有1%的死亡风险。然后系统地改变等待时间，直到患者放弃其最初的选择，从而得出条件性最大可接受等待时间。患者的态度存在差异，57%的患者最初选择等待6个月且有1%的死亡风险。条件性最大可接受等待时间得分的总体分布范围为1至26个月，中位数为7个月。效用值与患者对等待时间的耐受性独立但微弱相关（调整后的R平方=0.059，P=0.004）。将样本按中位数分为对等待耐受性相对“低”和“高”的亚组后，等待耐受性明显较低的亚组报告的效用得分较低（z=2.951；P=0.004），且自外科医生首次告知他们需要手术以来的时间较短（z=3.014；P=0.003）。这些结果表明，在建立和监测旨在提高生活质量的手术排队管理系统时，应考虑患者自身对其总体症状负担的认知以及耐受延迟缓解的能力，同时结合临床判断和预先加权的健康状况工具所获得的信息。
