New Zealand Health Agencies Use 1000minds to Develop a General Surgery Prioritisation Tool

A study published this month in Health Policy details the use of 1000minds by New Zealand health agencies to create a transparent and equitable national surgery prioritization tool.

The New Zealand Ministry of Health (MoH) collaborated with the professional bodies of the General Surgery craft group (RACS and NZAGS) to create the tool.

The study found that the 1000minds tool was a reliable and effective method for prioritizing patients, citing its high correlation with clinical judgement. In addition, the prioritization methods are transparent, and results have been able to be reproduced consistently.

A majority of clinicians are in support of the tool, which could decrease inequities in access to healthcare. In the past, the use of local versus national tools for prioritizing patients has created geographic disparities in people’s ability to receive treatment. Furthermore, Māori and Pacific people have often been subject to delayed treatment compared to New Zealanders of European background.

With the 1000minds tool, pilot studies have found no significant impact of age, gender and ethnicity on patient score. Implementing this tool nationally would therefore help mitigate concerns about equitable treatment for all.

In addition, unlike clinical judgement, the tool is transparent in showing how patient prioritization scores are derived.

Not all clinicians are in favour of the tool, however. Some express concerns about subjectivity and clinician manipulation of the tool.

Currently, one of the tool’s criteria is the “patient-derived impact on life”, which requires a patient to rate how severely their life is being impacted by their health condition. Because this score is subjective to each individual, it may not provide accurate insight on a patient’s condition.

“Some who should have surgery will 'play down the impact' and those with a more 'emotional' disposition will score it much higher. Therefore the same patient-derived impact on life by different patients may not be the same.”

Another issue is that clinicians may “game” the system to prioritize their patients more than others. Once a clinician becomes familiar with what increase in points may lead to a higher ranking, they may input the values accordingly and thereby manipulate the system.

However, solutions have been proposed to mitigate these issues.

Instead of assessing the “patient-derived impact on life”, the criterion can be substituted with one that can be measured readily and consistently, such as the frequency of doctor’s visits, time off from work, and medication for coping with the condition. And the criterion as it is may not even pose a problem at all: research shows a high correlation with patient-derived quality of life and clinical priority.

With respect to potential manipulation of the tool, experts suggest an inbuilt audit system that would help monitor these inputs and ensure equitable access to treatment for all patients.

The MoH began nation-wide implementation of the 1000minds general surgery prioritization tool in 2018. While stakeholders agree that continuing evaluation of the tool is necessary in order to evaluate possible disparities, the authors of the study conclude that the tool is a reliable, transparent, and clinically accurate method of assessing priority.

View the full study here: 

G Srikumar, T Eglinton & A MacCormick (2020), “Development of the general surgery prioritization tool implemented in New Zealand in 2018”, Health Policy 124, 1043-49

Highlights

  • The prioritization tool was developed for general surgery in New Zealand and implemented in 2018.
  • The majority of surgeons and other stakeholders supported the proposed tool.
  • Concerns included subjectivity, manipulation, equity of access and degree of benefit obtained.
  • Overall, the tool demonstrates reliability, transparency and reflects clinical judgement.

Abstract

Patients waitlisted for elective general surgery in New Zealand used to be prioritized by multiple tools that were inconsistent, did not reflect clinical judgement and were not validated. We describe the development and implementation of a national prioritization tool for elective general surgery in New Zealand, which could be applicable to other OECD countries. The tool aims to achieve equity of access, transparency, reliability and should be aligned with clinical judgement. The General Surgery Prioritization Tool Working Group commenced development of a prioritization tool in 2014 which showed strong correlation with clinical judgement (r = 0.89), excellent test-retest reliability (r = 0.98) and significantly lower variability (p < 0.001). Preliminary findings showed no significant difference in scores attributable to age, gender or ethnicity. General Surgeons were in favour of the tool criteria and agreed on the importance of prioritization; however a minority opposed its introduction. Health organizations and general practitioner groups were in favour, however, along with many surgeons, expressed apprehensions regarding subjectivity, manipulation, equity of access and degree of benefit. Despite reservations, the majority of stakeholders were supportive and through collaboration between clinicians and the government, the tool was implemented in 2018 in New Zealand. Overall, the prioritization tool is a reliable method of assessing priority, demonstrating transparency and reflecting clinical judgement, with equity of access to be further assessed by evaluation in clinical practice.