WAITING FOR CORONARY REVASCULARIZATION IN TORONTO - 2 YEARS EXPERIENCE WITH A REGIONAL REFERRAL OFFICE

Objectives: To determine the frequency of major adverse events among p atients awaiting coronary revascularization; to assess the match betwe en referring physicians' estimates of urgency, a computer-generated mu ltifactorial urgency rating score and actual waiting times; to determi ne the changes in waiting times as capacity for bypass surgery increas ed; and to evaluate the influence of choice of procedure or operator o n waiting times. Design: Consecutive case series. Setting: Greater Tor onto region. Subjects: All 571 patients referred to an organized refer ral office by cardiologists at hospitals without on-site revasculariza tion facilities between Jan. 3, 1989, and June 30, 199 1. Main outcome measures: Preoperative fatal or nonfatal myocardial infarction; propo rtions of patients waiting longer than the maximum period recommended for their urgency rating; mean waiting times for various subgroups; an d correlations among referring physicians' urgency ratings, computer-g enerated multifactorial urgency scores and waiting times. Results: Of the 496 patients accepted for a procedure 5 had fatal cardiac events a nd 3 nonfatal myocardial infarction. Events occurred three times more often in patients with left main-stem disease than in those in other a natomic categories (relative risk [RR] 3.05, 95% confidence interval [ CI] 1.48 to 6.27, p = 0.03). Both the computer-generated scores and th e referring physicians' scores were correlated with the actual waiting time (r = 0.46 and 0.57 respectively). Waiting times and the proporti on of patients with excessive waiting times fell during the study peri od (p < 0.0001). However, urgent cases were much less likely to be don e ''on time'' than those with a recommended waiting time of more than 2 weeks (RR 0. 16, 95 % CI 0.11 to 0.25, p < 0.0001). The mean wait fo r coronary artery bypass grafting (CABG) was 22.73 days if the referra l office was allowed to find a surgeon or interventional cardiologist and 35.31 days if one was requested (p = 0.002 after adjustment for ur gency scores). Conclusions: Death of a patient on the waiting list is uncommon in an organized referral system. Patients with left main-stem disease are at higher risk of death than those in other anatomic cate gories. There were significant correlations between referring physicia ns' ratings of urgency, multifactorial urgency scores and actual waiti ng times. Expansion of capacity for CABG led to shorter waiting times, but patients with unstable symptoms continued to wait longer than rec ommended. Requests for a specific surgeon caused significantly longer delays.