Every morning, the neurosurgeons refer to the correspondence to determine who will proceed with their elective cases. Documentation of those surgeons affected by cancellations is made for future reference in order to minimize repeated cancellations to the same group of individuals. A monthly audit of surgeon cancellation is performed and the process is reviewed. With each iteration, more items are added to the list of possible factors that may influence priority setting.
Pearl
Priority setting may not be relevant in circumstances where hospital resources are essentially unlimited, such as in some private hospitals. On the other hand, priority setting in very low resource settings, including many developing countries, is associated with additional challenges. These include availability of drugs, equipment, and ICU beds.
21.4 Discussion
21.4.1 OR Cancellations: An Everyday Challenge for Neurosurgeons
All health-care systems must find solutions to challenges that arise as a result of resource limitations. One very common example in neurosurgery is the cancellation of elective ORs, which may occur for a variety of reasons, including facility limitations, overrun of previous surgeries, or patient- and surgeon-related factors. This problem has been described in multiple health-care systems in all parts of the world (Argo et al. 2009; Chiu et al. 2012; Garg et al. 2009; Gonzalez-Arevalo et al. 2009; Haana et al. 2009; Kumar and Gandhi 2012; Lau et al. 2010; McIntosh et al. 2012; Mesmar et al. 2011; Schofield et al. 2005). Some authors have reported cancellation rates in excess of 30 % on the day of surgery. Although various studies have attempted to design more effective OR schedules to minimize cancellations (Pandit and Carey 2006; Pandit and Tavare 2011), the majority have not been found to be effective, as cancellations are typically very difficult to predict (Tung et al. 2010). Neurosurgeons, therefore, continue to struggle with how best to address elective OR cancellations. A mechanism to inform and guide such decision-making is therefore highly valuable.
21.4.2 Accountability for Reasonableness: An Ethical Approach to Systems-Level Decision-Making
A4R was introduced by Daniels and Sabin as a framework for ethical priority setting (Daniels and Sabin 1998, 2002). It is based on the premise that individuals unanimously agree that the decision-making process should be fair and ethically justified, although they may disagree on what factors are important to consider when constructing prioritization algorithms. This framework asserts that reasonable decision-making mechanisms should satisfy four primary conditions: relevance, publicity/transparency, revision/challengability, and enforcement/oversight (Table 21.2). This creates a tool by which decisions may be held accountable to the standard of reasonableness.
Table 21.2
Conditions of accountability for reasonableness as applied to OR prioritization decisions
Framework expectation | Explanation | Application to OR prioritization decisions |
|---|---|---|
Relevance | The process is based on factors that the stakeholders predetermine to be relevant | All surgeons agreed that A4R should be adopted to inform ethical prioritization decisions |
The list of factors used in the decision-making are deemed relevant | ||
Publicity/transparency | Distribution of the decisions as well as the factors involved in the decision-making process to all stakeholders | OR prioritization decisions are distributed to all stakeholders well in advanced of the day of OR |
Factors used in determining prioritizations are also distributed | ||
Revision | Opportunities to challenge the decisions are offered | All stakeholders are invited to appeal the decision should they have compelling reasons to challenge it |
Enforcement/oversight | A mechanism is in place to ensure that the three prior conditions are met | Oversight of the process occurs, for example, by auditing the decisions are predefined time intervals |
This framework may be applied to systems-level neurosurgical priority setting in order to render the process more fair and ethically justifiable. This may bestow benefits to patients, surgeons, and hospital administrators. No one likes bad news, but surgeons and patients can accept decisions that negatively affect them if they believe some thought, preparation, and ethical consideration went into the decision. In other words, most mature people can accept bad results as long as they know that the process leading to that outcome was fair and no one got special treatment. In the subsequent sections, we outline how the conditions of A4R may be satisfied in order to achieve an improved priority setting process for elective OR cancellations.
Pearl
The modern bioethical framework for assessing ethical priority setting is called the accountability for reasonableness. Its four elements are relevance, transparency, challengability, and oversight.
21.4.2.1 Relevance
The relevance condition of A4R states that under a given circumstance, decisions should be based on factors that stakeholders have predetermined to be relevant, in other words, good reasons. As applied to elective OR cancellations, all neurosurgeons in the previously described scenario recognized the need for the application of a fair mechanism for priority setting. This is important to establish formally, as it ensures that the individual neurosurgeons are committed to upholding the conditions of the framework.
At most neurosurgical centers, a single person is charged with prioritization of elective ORs in cases where cancellations may be encountered, and it is usually done in real time as opposed to in advance. Usually, this is the OR manager or Division Head. This is typically achieved using unclear, inconsistent, or arbitrary considerations. Furthermore, the process is typically “reactive,” that is, considered only when a cancellation is imminent. This is problematic as it may not result in fair or reasonable prioritization algorithms.
If asked, surgeons can agree on the factors that should be considered important when establishing prioritization schemes. Many of these are intuitive. For example, patients with more urgent conditions should have higher prioritization (e.g., cervical myelopathy trumps cervical radiculopathy, brain tumor with midline shift trumps small tumor with no mass effect). Furthermore, patient-specific considerations are taken into account. For example, most reasonable people would agree that those patients who were previously cancelled should be prioritized higher than those who were not previously cancelled, or patients who have come from a great distance might be prioritized over local patients. Other hospital- and system-specific factors may also be considered. For example, if the hospital receives incremental or additional funding for a certain subgroup of patients, they may be prioritized, providing that their care does not affect that of urgent patients. A list of sample factors that may be considered is presented in Table 21.3. Although these factors may differ from center to center, they should be unanimously deemed relevant by the stakeholders given the individual institution’s circumstances.
Table 21.3
Factors that may be used in priority setting
Categories | Relevant factors |
|---|---|
Case-specific factors | Urgency of case |
Extraneous funding available, which would not interfere with resources for other patients | |
Expected length of case (i.e., maximum number of cases that could get completed given different prioritization schemes) | |
Special surgical circumstances (i.e., stereotactic neurosurgery case where frame has already been placed on patient) | |
Patient-specific factors | Patient was previously cancelled |
Patient traveled a long distance to reach OR | |
Other unique patient circumstances | |
Surgeon-specific factors | Surgeon OR time recently affected |
Surgeon’s history of use of OR time | |
Other agreed-upon factors |
21.4.2.2 Publicity/Transparency
The second expectation of A4R is that of transparency. This is achieved in the above scenario by distribution of the prioritization decisions, as well as the factors taken into consideration to all stakeholders in advance of the OR date. This provides an opportunity for all surgeons to evaluate the decisions and propose amendments should they have compelling reasons to put forth a challenge. To meet this condition, there must be well-delineated definitions of who the stakeholders are. The individual neurosurgeons involved are certainly among the stakeholders, but depending on the health-care system and institutional policies, it may be appropriate to also involve OR managers, anesthetists, nursing staff, or other health-care professionals. This may be important as OR managers, for instance, may challenge the OR prioritization based on factors that are not known to the surgeons. Some groups may also view the patients themselves as stakeholders in the process. Ethical purists would suggest the patients, who are the ultimate stakeholders, should be privy to the prioritization, but most surgeons and administrators would likely be uncomfortable with that level of transparency. Certainly, on a personal level surgeons should exercise transparency to patients with messages like: “I’m so sorry your meningioma operation has to be cancelled tomorrow – I was on call on the weekend and several urgent cases were admitted. We’ll get yours done soon.” This kind of honesty and transparency reinforces patients trust in their surgeon and in the system.
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