Prioritization for coronary artery bypass surgery: can the process be improved?

5th International Conference on Priorities in Health Care

Alison Barber,* Fiona Doolan Noble, Ralph Stewart, Gerry Wilkins, Ray Naden & Diana North

*Project Manager – Electives Prioritization, Ministry of Health, 650 Great South Road, Penrose

INTRODUCTION: Historically demand for coronary artery bypass surgery (CABG) has exceeded publicly resourced capacity creating a natural threshold for access and a need to prioritize. Clinical Priority Assessment Criteria (CPAC) tools were developed to support this prioritization process. Anecdotally this process was not working and concerns of inequitable geographical access prompted review and refinement.

OBJECTIVES:
1. To ensure the development of a transparent and nationally consistent prioritization process that would support equitable access nationally.
2. To review and revise as necessary the current CPAC tool for CABG
3. To develop credible supporting information systems that facilitate quality improvement.

METHODS: The Ministry of Health (MoH) contracted two project leads (DN and FDN) to visit each regional surgical centre and:
- Gain an understanding of current prioritization processes for CABG patients
- Facilitate discussion around the decision making process from an elective services framework
- Build commitment to reviewing the prioritization process.

The final report highlighted eight areas of concern. Three areas of focus were agreed: Revise the current CPAC tool; develop an electronic CPAC tool and data collection system; and reduce the regional variation. The Cardiac Society of Australia and New Zealand (CSANZ) was approached to take a lead in the initiative; agreement was reached; steering and working groups were formed.

RESULTS: The current CABG CPAC tool has been revised in an iterative manner. Consideration has been given to what criteria to include, their subsequent categories, the rank order of the categories and the evidence that underpins them. A calibration process was undertaken using an electronic points weighting method – Point*Wizard (1000minds) and the revised tool validated using vignettes to determine reliability.

CONCLUSION: The CSANZ and the MoH have formed a partnership in an attempt to seek a responsible solution to this multifaceted issue. The initial results are promising, however the process is a dynamic one and the answer to satisfy all stakeholders remains elusive. It is hoped the process of collaboration that underpinned this review process will result in consistent prioritization for CABG across the regions, facilitating equitable access to the intervention.