Are Waiting List Prioritization Guidelines Being Followed in Australia?

Abstract

Objective. When waiting lists are used to ration treatments for nonemergency procedures, a prioritization rule is required to ensure that urgent patients are admitted first. This study investigates how the introduction of an explicit prioritization guideline affected the prioritization behavior of doctors, who previously had full discretion for assigning patients. Design. The analysis exploits the publication of recommended priority categories in public hospitals. Taking the recommendations as a reference, deviations from the recommended priority assignments by doctors before and after the guideline publication are assessed. Multinomial logit models are used to control for patient and hospital characteristics. Heterogeneity in the impact of the guideline across patient characteristics is explored through interaction terms. Setting. The state of New South Wales, Australia, between July 2004 and December 2010. Participants. Admissions via waiting lists in public hospitals ( N = 753,010). Main Outcome Measure. Priority categories assigned by doctors. Results. The guideline increased the likelihood that doctors would actually assign a semi-urgent priority to admissions with a recommended priority of semi-urgent by 11.7 percentage points ( P < 0.000) and would assign a nonurgent priority to admissions with a recommended priority of non-urgent by 13.1 percentage points ( P < 0.000). In contrast, the guideline lowered the likelihood of an urgent priority being assigned to admissions with a recommended priority of urgent by 13.7 percentage points ( P < 0.000). Priority assignments are affected by payment status; specifically, a higher priority is given to paying patients, and this preferential treatment is not diminished by the presence of the guideline. Conclusion. The presence of a simple clinical priority guideline at the procedural level has not produced systematic, clinically based prioritization behaviors among doctors. The New South Wales priority guideline has curtailed assignments to the highest priority. This result raises a question concerning the usefulness of such a guideline in improving timely and equitable access to health care.