Education And Debate

Urgency and priority for cardiac surgery: a clinical judgment analysis

BMJ 1998; 316 doi: (Published 21 March 1998) Cite this as: BMJ 1998;316:925
  1. F Kee, honorary senior lecturer (,
  2. P McDonald, research officerb,
  3. J R Kirwan, readerc,
  4. C C Patterson, senior lecturer in medical statisticsd,
  5. A H G Love, professor of medicinee
  1. a Department of Epidemiology and Public Health, Queen's University of Belfast, Belfast BT12 6BJ
  2. b Department of Public Health Medicine, Northern Health and Social Services Board, Belfast BT42 1QB,
  3. c Department of Rheumatology, University of Bristol, Bristol BS8 1QE
  4. d Department of Epidemiology and Public Health, Queen's University of Belfast
  5. e Department of Medicine, Queen's University of Belfast
  1. Correspondence to: Dr Kee
  • Accepted 5 August 1997

The Clinical Standards Advisory Group has expressed concern over the lack of clear criteria with which to accord priority to patients awaiting coronary artery bypass surgery.1 Until recently, the most notable research on what determines “urgency” was to be found in reports from Ontario which point to variations between doctors and institutions in the criteria they use to place patients in a queue.2-4 Earlier this year the New Zealand National Advisory Committee on Health published its findings on the impact that some social factors, such as the threat to independence, the care of dependants, or the patient's ability to work, might have on decisions related to priority.5

The influence of demographic or lifestyle factors, such as age or smoking habit, on waiting list priority has been debated prominently in the United Kingdom. 6 7 Doctors may take an individual view of the probable effectiveness of revascularisation in some patients (for example, smokers compared with non-smokers). However, neither the perceived efficacy of the procedure nor the distinction between “urgency” (the speed required to intervene to obtain a desired clinical outcome) and “priority” (the relative position on a surgical waiting list) has yet been investigated. Doctors might agree that a patient who smokes needs urgent intervention but disagree over the priority this patient should be accorded on a waiting list for surgery.

In response to the Clinical Standards Advisory Group report, a regional workshop sponsored by the Northern Ireland Clinical Resource Efficiency Support Team was convened in the spring of 1996 to address these issues. Two main research questions were:

• • Do clinicians pay attention to demographic and lifestyle factors when making urgency and priority judgments?

• • Do disagreements between clinicians arise out of differences in how they attend to clinical and demographic factors in arriving at …

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