Is Prioritization of the Sinus Surgical Waitlist Required?

Introduction Five percent of Canadians suffer from Chronic Rhinosinusitis (CRS) based on a national survey.1 CRS sufferers have debilitating facial pain, nasal congestion, nasal discharge and poor sense of smell. Relative to other chronic diseases, the quality of life of patients suffering with CRS is comparable to diseases such as congestive heart failure, chronic obstructive pulmonary disease, angina and back pain.3 Currently, CRS patients in Vancouver, British Columbia wait just over a year for surgery. British Columbia's (BC) health care policy recommends that CRS patients waiting for surgery be done in twelve weeks. It is well recognized that patients who wait longer than medically reasonable for surgery result in an excess costs, both directly to the patient, the healthcare system and the economy as a whole.5 Unfortunately, no studies done in Canada have illustrated the direct and indirect costs associated with CRS annually.

Patients' waiting time for elective sinus surgery in BC has come under public scrutiny in recent years. As a result, policy-makers are keen to address this waitlist issue.4 The government has identified sinus surgery as an elective day procedure that requires the Patient Focused Fund (PFF) to increase volume and address its disproportionately large waitlist. This likely has resulted in savings to VCH patients and the BC Health Ministry that would not have occurred had the PFF not been initiated. However, policy-makers must explore other innovate ways to supplement the PFF to provide further savings to VCH patients and the BC health care system.

An approach that has been adopted by other specialities such as orthopaedics, ophthalmology, and radiology is the use of a validated tool to prioritize waitlists.6-8 There are no validated tools published for prioritizing sinus surgery waitlists. The Canadian Institutes of Health Research provided funding to establish the Western Canada Waiting List Project (WCWL) to "improve the fairness of the health care system so that Canadians' access to appropriate and effective medical services is prioritized on the basis of need and potential benefit."9 Despite the work done by the WCWL being limited to five clinical areas (cataract surgery; general surgery procedures; hip and knee replacement; magnetic resonance imaging (MRI) scanning, and children's mental health), the methodology utilized in establishing their prioritization tool can be used to establish one for the sinus surgery waitlist;10 The impact of chronic diseases, including CRS, varies among patients11; therefore, prioritizing patients based on clinical measurements and cost-effectiveness from an individual and healthcare system perspective would be a novel approach to addressing waitlists for sinus surgery. Currently, VCH CRS patients are treated on a first come, first served basis. Despite this being the most transparent way of ordering the waitlist, the investigators feel VCH CRS patients need a waitlist system that promotes wellness and ensures care that focuses on quality - this can be achieved with a prioritized waitlist based on quality of life improvement and decreased healthcare expenditure.

Prior to establishing a validated tool for the prioritization of sinus surgery waitlists, one must first determine if VCH patients and the BC health care system would benefit from prioritized surgery. Providing a solution to this question requires moderate amount of resources and would take several of years to complete. The investigators propose a feasibility study coupled with an economic evaluation to determine if the disproportionately long wait list faced by CRS patients can be optimized and thus improve patient outcomes.

Current State of Knowledge Researchers must determine if CRS patients and the BC health care system would benefit from a prioritized waitlist for sinus surgery. It is accepted that sinus surgery compared to medical therapy improves the quality of life of CRS patients.12-14 However, to determine whether VCH CRS patients would benefit from a prioritized waitlist, the investigators must answer the following questions. If patients were to have surgery sooner: 1) how does their quality of life change with time compared to those on the waitlist? 2) do they experience a reduction in out of pocket costs?; 3) does the healthcare system experience a decrease in healthcare expenditure? and 4) is there are a subgroup of patients who would particularly benefit more than others from early surgical intervention? Providing this information is vital in determining if a prioritized waitlist would be beneficial for sinus surgery.