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Surgical assessment: measuring unobserved health Crump, Trafford; Wing, Kevin; Bansback, Nick; Sutherland, Jason M Jan 15, 2015

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STUDY PROTOCOLSurgical assessment: measMPatients typically do not have immediate access to elect- of patients wait more than four months for elective sur-Crump et al. BMC Surgery 2015, 15:4http://www.biomedcentral.com/1471-2482/15/4often a lengthy wait from the time a referral to a specialistis made until the time of the initial surgical assessment.CanadaFull list of author information is available at the end of the articleive surgery in Canada. Instead most patients have towait, and that wait time is comparatively longer than waittimes in other developed countries. Canada ranks as thepoorest performer among a sample of 11 industrializedgery and 41% of patients wait more than two months tosee a specialist [1]. For some patients, this wait time im-pacts their quality of life [2,3].Currently, provinces report surgical wait times startingfrom when patients are placed on the surgical wait listuntil the time of surgery. This snapshot provides limitedinsight into the actual duration of a patient’s wait. There is* Correspondence: jsutherland@chspr.ubc.ca4Centre for Health Services and Policy Research, School of Population andPublic Health, University of British Columbia, Vancouver, British Columbia,BackgroundAbstractBackground: The federal and provincial governments in Canada have invested an enormous amount of resourcesto measure, report and reduce surgical wait times. Yet these measures under-report the wait period that patients’actually experience, because they do not capture the length of time a patient spends waiting to see the surgeonfor a surgical assessment. This unmeasured time is referred to as the “wait one” (W1). Little is known about W1 andthe effects that this has on patients’ health. Similarly, it is not understood whether patients waiting for surgicalassessment actually want or need surgery. Existing administrative and clinical dataset do not capture informationon health and decision-making while the patient is waiting for care form a specialist. The objective of this proposedstudy is to understand the impact that W1 for elective surgeries has on the health of patients and to determinewhether this time can be reduced.Methods/Design: A prospective survey design will be used to measure the health of patients waiting for surgicalassessment. Working with the support of the surgical specialities in Vancouver Coastal Health, we will surveypatients immediately after being referred for surgical assessment, and every four months thereafter, until they areseen by the surgeon.Validated survey instruments will be used, including: generic and condition-specific health status questionnaires,pain and depression assessments. Other factors that will be measured include: patients’ knowledge about theircondition, and their desired autonomy in the decision making process. We have piloted data collection in onesurgical specialty in order to demonstrate feasibility.Discussion: The results from this study will be used to quantify changes in patients’ health while they wait forsurgical assessment. Based on this, policy- and decision-makers could design care interventions during W1, aimedat mitigating any negative health consequences associated with waiting. The results from this study will also beused to better understand whether there are factors that predict patients’ desire to proceed to surgery. These couldbe used to guide future research into experimenting with interventions to minimize inappropriate referrals andwhere they are best targeted.Keywords: Waiting lists, Access to health care, Referral and consultation, Secondary care, Elective surgicalprocedures, Health status, Quality of life, Health surveys, Longitudinal surveycountries in access to hospital care for adult patients; 25%healthTrafford Crump1, Kevin Wing2, Nick Bansback3 and Jason© 2015 Crump et al.; licensee BioMed Central.Commons Attribution License (http://creativecreproduction in any medium, provided the orDedication waiver (http://creativecommons.orunless otherwise stated.Open Accessuring unobservedSutherland4*This is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andiginal work is properly credited. The Creative Commons Public Domaing/publicdomain/zero/1.0/) applies to the data made available in this article,Crump et al. BMC Surgery 2015, 15:4 Page 2 of 8http://www.biomedcentral.com/1471-2482/15/4This time period, which we refer to as “Wait One” (W1),usually goes unmeasured, but represents an importantpart of a patient’s care experience.Little is known about patients’ health while waiting forsurgical assessment. Surgeons and referring physiciansreport that this wait time can be very lengthy and causesa significant disruption in patient’s care [4]. It is not clearhow many patients waiting for surgical assessment actu-ally wish to proceed to surgery. A study of patients’ treat-ment decisions after seeing an orthopaedic surgeon inOntario reported that 79.3% of patients did not get sur-gery, indicating that not all referrals may be appropriatefor surgical consultation [5]. The study’s authors positedthat many referrals to orthopaedics are for specialist inputinto the management of the underlying condition, andsuggest that further research is needed to better under-stand the kind of patients being referred to surgical spe-cialties and the reasons for those referrals.ObjectiveThe objective of this proposed study is to understand theimpact that W1 for elective surgeries has on the health ofpatients and to determine whether this time can be re-duced. This objective will be met by answering four re-search questions:(1) What is the length of time patients spend waitingfor their initial surgical assessment?(2) What is the change in health status that patientsexperience while waiting for their initial surgicalassessment?(3) What are patient factors associated with thedecision to proceed with surgery?(4) Does self-reported information help to discriminatebetween warranted and unwarranted referrals?This study is being undertaken in collaboration withseveral surgical groups practicing in Vancouver CoastalHealth (VCH) authority. This research team has stronghistorical relationships with many specialty surgical groupspracticing in VCH’s six hospitals, the VCH executive teamand the British Columbia (BC) Ministry of Health, ensur-ing the study’s feasibility and maximizing the likelihoodthat the findings from this study will be incorporated intodecision- and policy-making processes.A brief review of the literatureHow long do patients wait for elective surgical assessment?There are no population-based provincial initiatives thatcollect patients’ health information while they are wait-ing for surgical assessment in Canada. Published litera-ture on the period between referral to, and assessmentby, a surgical specialty are limited to individual special-ties reported at a single instance in time – nor do theystudy health outcomes or the decision-making processes.In 2005, the Canadian Association of Gastroenterologyreported that the median wait time to see one of theirspecialists for inflammatory bowel disease (which has atwo-week target) was 101 days (inter-quartile range 35–209 days) [6]. In 2006, the Canadian Institute for HealthInformation (CIHI) reported that for patients having hipor knee replacement surgery, 30% of their overall waitwas for the initial assessment [7]. Another study of waittimes from referral to surgical assessment for hip andknee arthroplasty in Alberta determined that the meanwait time for this period ranged from 51 to 139 days [8].The study identified that approximately 40-80% of thewait time for patients was during the wait for surgical as-sessment [8]. One study in Ontario used general practi-tioner (GP) electronic medical records to track wait timesto see a specialist over a five year period [9]. The studyfound high variability in wait times based on specialty andGP practices, men had a shorter median wait then women(51 and 55 days, respectively) and younger patients hadthe shortest median wait at 45 days [9].What are the consequences of waiting for elective surgicalassessment on patients’ health?There is an absence of comprehensive data currently avail-able regarding the effects of waiting for elective surgicalassessment on patients’ health. This information is crucial,since delays in access to healthcare services for other,non-elective conditions, have been shown to affect the tra-jectory of care. Research conducted by Prentice and Pizerstudying wait times in the Veterans Administration in theUnited States observed that delays in accessing outpatientservices for ambulatory care sensitive conditions, such assurgical assessment, significantly increased the odds of be-ing hospitalized if these delays were over 29 days; if over31 days, the odds of mortality increased [2,3].Who is waiting for elective surgical assessment?Critically, there is not much information regardingwhether patients waiting for elective surgical assessmentreally need – or want – surgery. A study in Queensland(Australia) evaluated the effect of implementing a GP re-ferral system aimed at addressing the high wait times fornon-urgent specialist appointments [10]. Patients on await list who were identified as having long waits weresent letters offering two options: to indicate that the ap-pointment with a specialist for surgical consult was nolonger necessary or to update their referral [10]. In the ini-tial stage, 872 patients who had long waits for orthopaedicsurgeries were identified and 101 responded, and only 16of those patients proceeded to surgery [10]. In an ex-panded program, over 6,885 patients waiting for multiplespecialities were contacted. Of these, 633 responded and197 required surgery [10]. This Australian study helps toCrump et al. BMC Surgery 2015, 15:4 Page 3 of 8http://www.biomedcentral.com/1471-2482/15/4underscore that there are a number of patients on the waitlist for surgical assessment that may not choose to be, orremain, there.Taken together, these studies paint a picture of a sig-nificant gap in our understanding of the nature of, andchanges in, patients’ health and decision making duringW1. Addressing this gap in knowledge would provideinvaluable insight to patients, clinicians, regional healthauthorities who manage access to surgical resources andgovernment stakeholders who are ultimately responsiblefor ensuring effective and efficient use of healthcarespending.Conceptual frameworkThe conceptual basis for this proposal is adapted from ataxonomy proposed by Wennberg et al., in which theutilization of healthcare is classified into one of threecategories: effective care, preference-sensitive care andsupply-sensitive care [11]. Effective care refers to thoseclinical scenarios that have an efficacious clinical path-way defined by medical evidence, such as hip fracturerepair or appendectomies. This is generally not so forelective surgical care targeted in this study, thus we focuson the latter two categories.Preference-sensitive care is care for conditions wherethere is more than one option for treatment and forwhich the scientific evidence regarding the effectivenessof these options is equivocal [12]. Preference-sensitive careis similar to elective surgical care, where surgery may beone of several treatment options available to the patient.For example, with knee osteoarthritis several non-surgicaltreatments are available, including weight loss, exercise orsteroid treatment. Surgical options for treatment includeosteotomy and partial or total knee replacement [13].In order to provide high quality preference-sensitivecare, physicians must take into account a patient’s prefer-ence for care and their health goals [12]. This requires thatpatients be fully informed and have confidence in their de-cision regarding the treatment choice that best meets theircare needs. The quality of referrals for preference-sensitiveconditions depends on a patient’s understanding of treat-ment options, the potential risks for harms and benefitsassociated with those options and on patient confidencein their decision to have surgery [12]. We define qualityreferrals as “appropriate”, and no further policy interven-tions are necessary. Inappropriate referrals do not followthis process.Supply-sensitive care is care that is based on a localhealth system’s availability of resources rather than onclinical evidence or a patient’s preference for treatment.Referrals made in this context imply that decisions re-garding surgical procedures are based on maximizingavailable capacity (e.g. operating room time) instead ofproviding the best care for patients [11,14]. We considerreferrals that do not match patients’ preferences or thatare made because of the availability of local surgical re-sources to be “inappropriate”.Identifying health system, patient and referring phys-ician characteristics associated with inappropriate refer-rals for preference- and supply-sensitive surgical care isthe basis for this proposed study. Inappropriate referralsto surgical assessment require intervention for two rea-sons. First, they lead to patients’ unnecessarily occupyingspace on wait lists for surgical assessment at the expenseof patients with appropriate referrals for surgery. Second,inappropriate referrals could be deferred to patient educa-tion interventions or active surveillance programs insteadof consuming the time and resources of specialists andscarce hospital resources.The interaction between patients and physicians duringthe decision to be referred for surgery is governed by theirrelationship as illustrated on the left half of Figure 1. Re-ferring physicians are often GPs, but may also be otherspecialists, either within or outside the speciality to whichthe patient is being referred for surgery. The referringphysician is likely familiar with the patient’s medical his-tory, has an established relationship with the patientand may be aware of that patient’s specific health goalsor concerns.Patients’ health goals, well-being, and knowledge levelwill be factors in their decision to be referred to surgery.Although not all patients wish to be involved in thetreatment decision-making process, those that are reportgreater quality-of-life scores and less regret about theirtreatment [15,16]. To understand the role these factorsplay in referrals and decision to proceed with surgery,this proposed study will measure health, functional well-being and knowledge level at the time of referral forsurgery. These measures will be regularly retaken overthe course of the W1 period in order to track any changesand their potential impact on a patient’s decision toproceed with surgery.The interaction between the patient and the surgeonin the decision to proceed with surgical treatment is illus-trated on the right half of Figure 1. The patient’s measuredlevel of health, knowledge regarding their condition, anddecision confidence may have changed while waiting, thusaffecting their decision to proceed with surgical treatment.Using statistical models for repeated measures, we will in-corporate changes in patients’ level of health, knowledgeregarding their condition and decision confidence overtime, and its potential effect on surgical treatment.Surgeons also play a role in the decision of patients toproceed to surgical treatment. Surgeon effects will be in-cluded in our statistical models to reflect treatment pref-erences, as well as age and utilization profiles. The endpoint of the study is, based on the surgical assessment,the patient’s decision to proceed with surgical treatmentpaCrump et al. BMC Surgery 2015, 15:4 Page 4 of 8http://www.biomedcentral.com/1471-2482/15/4or not. The modalities of treatment prior to referral tosurgical assessment are outside of the scope of this studyand will be pursued in the future.Methods/DesignTo answer the research questions in this proposed study,we will use a prospective longitudinal survey design.Study participants will be surveyed at regular intervalsfrom the time they are referred for an elective surgicalprocedure until the time of their initial surgical consult-ation. For our purposes, this design is superior to cross-sectional surveys, where patients are asked retrospectivelyFigure 1 Conceptual model for the collection and measurement ofof their experiences. Retrospective studies are subject torecall bias and patients rate their health state higher asthey adjust to limitations over time [17].Target populationOur sampling frame is those patients newly referred to asurgeon in one of the surgical specialties identified inTable 1 who are practicing in Vancouver, BC. The studywill recruit patients referred for an elective surgical pro-cedure from either primary care providers or from otherspecialties (i.e. cross-referrals). These surgical specialtieshave been selected for two reasons. First, they representTable 1 Procedures of interest by surgical specialtyGeneral surgery OrthopedicsLaproscopic cholecystectomy Elbow reconstructionFemoral hernia repair Knee ACL reconstructionVentral hernia repair Shoulder rotator cuff repairInguinal hernia repair Ankle arthritisGastrointestinal bypass Bunion repairHemorrhoidectomieselective surgical procedures that can be consideredpreference-sensitive and non-surgical treatment optionsmay be available. Second, we have pre-established rela-tionships with surgeons in these surgical specialtiesthrough other studies. While there may be selection biasamongst those specialities that have agreed to partici-pate, there is no reason to believe that patients of thesesurgeons are systematically different from the populationas a whole.These surgeons have agreed to share their referral datawith the study team. Patients will be contacted by theresearch team once the referral is received by the surgeon’stients; health data while waiting for surgical assessment.office. Though there will be a gap between the patient’s visitto the referring physician and the receipt of the referral bythe surgeon’s office, we expect this gap to be less than sevendays and to have a negligible effect on the study’s data.Sampling inclusion / Exclusion criteriaAll patients who have been referred for an elective surgi-cal procedure in Table 1, who are over the age of 18,and who are able to provide verbal and written consentin English will be recruited for the study. Patients will beexcluded if they are facility-bound, are unable orPlastic surgery UrologyBreast reconstruction Penile prosthesisMammoplasty reduction Bladder suspension slingAbdominoplasty Urinary artificial sphinctersHand tendon repair Transurethral resection of the prostateMandibular fractureCrump et al. BMC Surgery 2015, 15:4 Page 5 of 8http://www.biomedcentral.com/1471-2482/15/4unwilling to provide consent or if they demonstratesigns of severe depression or suicidal tendencies.Recruitment strategyWhen a referral is received by the surgeon’s office, thepatient will be asked by the office if they wish to be in-volved in this study. Patients that are interested will havetheir contact information securely transferred to a mem-ber of the study team. This team member will contact thepatient over the telephone, explain the study, emphasizethat it will have no impact on their wait time to see thesurgeon and obtain verbal consent. Patients that provideverbal consent will be mailed a written informed consentwith their initial survey.SurveyAn initial survey package will be sent to participants andwill include: 1) an information brochure outlining thestudy, 2) an informed consent form to be signed (in du-plicate, so the participant may keep a copy), 3) context-ual questions regarding their socio-demographic status[18] and most common co-morbidities and 4) questionsreading their health status, knowledge about their condi-tion and their decisional conflict (see Measures sectionbelow). Participants may opt out of any question(s) theyare not comfortable answering. A self-addressed stampedenvelope will be included in the package.Data collection proceduresThe initial survey will be mailed as soon as verbal con-sent is received, within a week of the referral being re-ceived by the surgeon’s office. Subsequent surveys willbe mailed every four months until the participant hastheir consultation with a surgeon. The last point of sur-vey will be just before the surgical assessment. Patientsmay have different numbers of survey points becausethe WI period varies by speciality and surgeon. We willidentify which patients progress to surgery with the as-sistance of the surgeon’s office.Survey managementA survey management database will be created for thepurpose of organizing and coordinating the inbound andoutbound survey packages. To cut down on labour needs,the data entry process will be automated by designing andprinting surveys on scannable forms. Only the study’sprincipal investigator, survey coordinator and data entrystaff will have access to the database. The statistician willhave access to de-identified data.Participant retentionTo enhance participant retention, reminders will be mailedout if survey packages are not returned within two weeks,followed by a telephone call if the survey package is stillnot returned.Sample size estimation strategy and power analysisThe study will contact each patient referred for a surgi-cal assessment for the surgical specialties included inTable 1. Precise estimates of procedures for power calcu-lations are derive from historical utilization patterns.Based on surgical utilization statistics, there were at least200 procedures conducted in 2010/2011 for each urologyprocedure in Table 1, providing 200 potential study pa-tients per year for each procedure, noting that VancouverGeneral Hospital and St. Paul’s Hospital act as a provincialreferral centre for a number of specialized procedures,while other specialties have similar, or greater, number ofpotential study patients.This pool of recruits provides a sampling frame of 700patients for each procedure (of the four year study de-sign, we will recruit patients for 3.5 years). Among these,we expect that we will recruit approximately 48% of pa-tients, leaving the study with 336 patients per procedure.Given our experience in similar studies, we expect to re-tain 70% of patients throughout the observation period,or observe complete data on 235 patients (equal to 700times 0.48 times 0.70).The assumed effect size of 0.2 SD is inferred from pre-vious studies. To detect a treatment effect size over theW1 time of 0.2 standard deviation (SD) on decline inhealth, and probability of proceeding to surgical treat-ment, our study will require 220 patients, presumingalpha = 0.05 (two-tailed) and beta = 0.20 (power = 80%).Therefore, relative to our projected recruitment, ourstudy is adequately powered to detect moderate sized ef-fects in each surgery.Consent and protection of confidentiality in dataTo ensure confidentiality of data, all study participantswill be provided a unique study identifier which will bekept physically separate from patient-identifying infor-mation. A computer file matching the patient to theirunique study identifier will be encrypted and kept on aseparate hard disk. This study has been approved by UBC’sBehavioral Research Ethics Board (BREB).MeasuresTable 2 provides an overview of the survey instrumentsthat will be used in this proposed study. These instru-ments were selected because they are short, validatedquestionnaires that will not overly burden participantsand have no or minimal licensing costs. We chose thoseinstruments that provide a single score that can be com-pared across time (intra-participant comparison) and par-ticipants (inter-participant comparison). All instrumentswill be administered to the participant for the initialiety/depression [19], which are scored using five levels.Generic assessment of health status EuroQol EQ-5D (5 L)Sense of certainty with the treatment Decisional Conflict ScaleCrump et al. BMC Surgery 2015, 15:4 Page 6 of 8http://www.biomedcentral.com/1471-2482/15/4It also includes one vertical visual analogue scale onwhich the individual ranks their overall health status bymaking a mark along a line anchored by the endpoints(baseline) survey. Subsequent surveys will exclude the co-morbidity questionnaire.Generic assessment of health statusFor the purposes of this study we use the EQ-5D-5 L tomeasure generic health status. The EQ-5D-5 L has beentranslated into 100 languages and is freely available touse, with no restrictions on publications. It is designedfor self-completed post surveys and is easy to administerwith minimal cognitive demands for study participants,taking only a few minutes to complete. The EQ-5D-5 Lis widely used internationally and health states valuationnorms have been validated in a Canadian population[19]. The EQ-5D-5 L has five questions addressing mo-bility, self-care, usual activities, pain/discomfort and anx-decisionDepression measure Patient Health Questionnaire(PHQ-9)Pain measure PEG-3Condition-specific assessmentof health statusVaries, depending on theprocedureAssessment of medical andpsychological syndromesCo-morbidity questionnaireUnderstanding of condition Knowledge questionnaireTable 2 Patient reported outcome measure surveyinstruments and accompanying descriptionDescription Instrumentlabeled “best imaginable health state” and “worst imagin-able health state”.Depression measureTo assess depression in patients’ we will use the PatientHealth Questionnaire (PHQ-9). This instrument addressesboth symptoms of depression and functional impairment[20]. There are nine questions regarding the presence ofdepression-related symptoms which are answered using afour-point Likert scale ranging from “not at all bothered”to “bothered nearly every day”.Pain measureThe PEG-3 will be used to assess pain in patients. ThePEG has one intensity item and two interference items,for a total of three questions. Responses to the instru-ment’s three items are given a value between 0 and 10.Assessment of medical and psychological syndromesThe research team has developed a questionnaire to as-sess the presence of common co-morbidities that maycontribute to a patient’s clinical complexity. This ques-tionnaire asks patients to report whether they have beendiagnosed with common chronic, acute, or mental healthconditions in the last three years. Responses to the ques-tionnaire are not scored, rather they are used as a patient-level adjustment when analysing the study’s results.Understanding of conditionA knowledge questionnaire asks patients about theirunderstanding of their clinical problem, the treatmentoptions available for that problem and the main benefitsand potential side effects associated with those options.The knowledge questionnaires will be developed in con-junction with each of the participating specialities. Previousstudies have generally developed a 6–8 item questionnaireusing a multiple choice response format that have highdegrees of internal consistency (alpha 0.82-0.83) andsensitivity to change [21-23]. These are scored based onthe number of correct responses.Certainty with treatment decisionThe Decisional Conflict Scale will be used to assess a pa-tient’s certainty about treatment. It is a validated, 16-item questionnaire [24]. Patients respond using a fiveitem Likert scale, based on their level of agreement witha statement. High decisional conflict is associated withthose patients who feel uninformed about their options,are unclear about their own personal values, or feel un-supported in making a decision.Preliminary dataTo demonstrate the feasibility of recruiting patients intoa study of this type and collecting patient-reported out-comes during the time that patients are waiting forsurgical assessment, the study team conducted a pilotwith orthopaedic surgeons in Vancouver. The study teamworked with the surgeon’s staff to identify newly referredpatients. A standardized script was prepared and used bythe surgeon’s staff to summarize the study and describe thesurvey. Subsequently, patients were mailed a consent formand survey package. Completed packages were mailed tothe surgeon’s office.Fifty-five consecutive patients were contacted by thesurgeon’s staff to determine whether they were willing toparticipate. Of those, three declined to participate and52 surveys were mailed to patients. Of these patients, 27ultimately returned the completed survey package withall assessment instruments completed, for a responserate of 48% (27 patients of 55 contacted).The pilot of orthopaedic patients demonstrates thefeasibility of collaborating with surgeon’s clinics to recruitCrump et al. BMC Surgery 2015, 15:4 Page 7 of 8http://www.biomedcentral.com/1471-2482/15/4patients newly referred to surgical assessment and to col-lect standardized patient health reported health, pain anddepression measures during their wait.DiscussionThere is an assumption in Canada that lengthy wait timesfor specialist consultations are an indicator of a poorly-performing healthcare system which can be resolved byexpanding surgical supply or hospital capacity. In truth,there is little evidence regarding the effect of W1 on pa-tients’ health and whether expanding surgical capacitywould have any impact on outcomes. Given the invest-ments federal and provincial stakeholders have made intoimproving access to elective surgical care, it is troublingthat so little is known about the effects of waiting on pa-tients’ health.The conceptual model described above suggests thatthere is an opportunity to lower the W1 period. If thereare specific characteristics that identify patients who arenot certain of their decision to have surgery and are un-likely to proceed to surgery, yet still are on the wait listto be assessed by a surgeon, we could design algorithmsto identify these patients in order to care for them innon-surgical ways. This would lower the wait time forthose patients with appropriate referrals and improve theoverall quality of healthcare by better matching treatmentswith patients’ preferences.Potential limitationsWe are confident that this prospective longitudinal sur-vey design is matched to meet the study’s objectives, butit has several limitations. These surveys suffer from sam-ple attrition as patients drop out. Sample attrition is un-avoidable in community-based studies, but through theuse of reminders and communication with surgeons, wewill take steps to mitigate attrition by making remindercalls and providing instructions to patients on how toupdate their contact information.Self-selection bias is also a limitation of this survey de-sign. We cannot be certain that those patients who optout of the study do not systematically differ somehowfrom those that opt in. To address this we have allocateda significant budget to recruiting and following-up withparticipants.Repeated questioning may cause participants tochange their responses over time, a phenomena referredto as panel conditioning [25]. To mitigate this, we haveminimized our survey points to every four months.Potential outcomes and future applicationsThis study will provide evidence to confirm or invalidatethe theory that waiting for surgical assessment for elect-ive surgeries is associated with negative consequencesfor patients’ health. If the results from this study do notindicate that waiting for elective surgical assessment hassignificant consequences for patients’ health, then thisstudy challenges perceptions regarding wait times.The knowledge gained from this study can be used toinform both policy-makers and clinicians regarding thehealth impact of waiting. For policy-makers, evidencefrom this study may form a foundation for decisions tobrake (or accelerate) policy interventions designed to ex-pedite surgical access. For clinicians, this study couldidentify opportunities to reduce inappropriate referrals forelective surgery either through better patient education in-terventions or improved shared decision-making.AbbreviationsBC: British Columbia; BREB: Behavioral Research Ethics Board; CIHI: CanadianInstitute for Health Information; CIHR: Canadian Institutes for HealthResearch; GP: General Practitioner; UBC: University of British Columbia;VCH: Vancouver Coastal Health; W1: Wait one.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsTC contributed to conception and design of this research protocol; wasresponsible for drafting, reviewing, and revising versions of the researchprotocol; and agrees to be accountable for all aspects of the work, ensuringthat questions related to the accuracy or integrity of any part of the workare appropriately investigated and resolved. NB contributed to the design ofthis research protocol, and was involved in its review and revision forimportant intellectual content. KW contributed to the conception of thisresearch protocol, and was responsible for acquiring the preliminary dataand assisting in its interpretation. JM contributed to conception and designof this research protocol; was responsible for drafting, reviewing, andrevising versions of the research protocol; and agrees to be accountable forall aspects of the work, ensuring that questions related to the accuracy orintegrity of any part of the work are appropriately investigated and resolved.All authors read and approved the final manuscript.AcknowledgementsThe authors would like to acknowledge contributions made by: MatthewBair, Angie Chan, Mark Chase, and Nadya Repin.Author details1Department of Pediatrics, Medical College of Wisconsin, Center for ClinicalEffectiveness Research, Children’s Hospital of Wisconsin, Milwaukee, WI, USA.2Department of Orthopaedic Surgery, School of Medicine, University ofBritish Columbia, Vancouver, British Columbia, Canada. 3School of Populationand Public Health, University of British Columbia, Vancouver, BritishColumbia, Canada. 4Centre for Health Services and Policy Research, School ofPopulation and Public Health, University of British Columbia, Vancouver,British Columbia, Canada.Received: 6 November 2014 Accepted: 9 January 2015Published: 15 January 2015References1. 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