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Table 2 Study characteristics of the seven original research articles included for the review with the overall risk of bias evaluation

From: The effectiveness of different patient referral systems to shorten waiting times for elective surgeries: systematic review

Author and year Country Research method Elective surgery Objectives Research setting Participants, Research period, and intervention Conclusions & recommendations Risk of Biasa
Damani et al., [38] Canada Quasi-experimental approach with pre-post cohort design Total knee/hip replacement (TKR) surgery To evaluate waiting time variations among surgeons, proportion of patients receiving surgery within benchmark, Influence across five dimensions of quality of care based on system- level and patient- centred outcomes (Quality accessibility, acceptability, appropriateness, effectiveness and safety). Provincial health authority Data were collected both before (June 2011–June 2012) and after implementation (September 3013–September 2014). Improve patient access to surgery by distributing referrals to the surgeon with shortest waiting time (next- available surgeon) and increase the proportion of patients treated within benchmark. Intervention helped to improve accessibility by reducing waiting time variability among surgeons, all waiting times for TKR and increasing proportion of TKR within benchmark (5.9%). ROBINS-I Moderate
Gabbay et al., [39] Israel Quasi experimental approach with historical prospective study Cataract surgery To evaluate the efficiency of referral triage system which schedules most cataract patients to surgery based on referral letters, with surgery done immediately following the preoperative examination. A Tertiary referral hospital Evaluated the performance of the new referral triage system (2015, 12 months) by studying the reason for day-of surgery cancelations against retrospective system. The novel approach of preoperative triage using referral letters for scheduling surgery, thus minimizing both patient and physician time prior to surgery and direct referral could shorten both costs and time to surgery. ROBINS-I Moderate
Coyle et al., [40] Canada prospective, blinded, randomized controlled study Neurosurgery; Elective Lumbar Spinal Surgery To evaluate whether a self-administered 3-item questionnaire (3IQ) could reprioritize referral appointments and reduce wait times. Canadian academic tertiary care centre 280 patients included within 24 months. Randomly assigned to surgeon triaged and patient triaged two groups, assessed for re-prioritisation status and the waiting time. Reduced the waiting time of intervention group and to identify non-surgical candidates for appropriate managements. Demonstrated the benefit of patient-reported assessments in prioritisation. ROBINS-I Low
Do et al., [42] Australia Cross-sectional study with longitudinal follow-up Cataract surgery To determine the content and diagnostic accuracy of cataract referral letters and assessed whether referral information had sufficient detail to triage patients and inform surgical prioritization. Two metropolitan public hospitals A review of referral letters and hospital medical records was undertaken for a total of 400 (2014). Reviewed same after 1 year. Current referral letters do not have sufficient detail to inform prioritization, and any efforts to prioritize waiting lists will require standardization of cataract referrals. Development of standard referral templates and resources to triage referrals may improve access to surgical services in a timely manner. ROBINS-I Moderate
Loginov et al., [41] USA Observational study Elective surgery To examine patient perspectives on surgical case scheduling, referral and wait time. Mayo Clinic 135 respondents completed the survey (2011–2016). The survey had three attributes; patient desired maximum waiting time, choice of date and option to change the surgeon. There was a positive association between the maximum waiting times sufficient to discuss having another surgeon perform the procedure. CASP
Diamant et al., [43] Canada Retrospective study Bariatric surgery To examine the impact of patient and operational factors on wait times in a multidisciplinary bariatric surgery program. Toronto Western Hospital 1664 referred patients included for the survey (June 2008–July 2011). Waiting time associations screened for the 724 who underwent surgery. Specific patient profiles and longer waiting are associated. Waiting time did not depend on BMI, age, sex and distance from the bariatric centre. Substance use was associated with longer preoperative evaluation.
Certain types of patients should be identified early in the referral process.
ROBINS-I Moderate
  1. aRisk of bias in intervention studies were assessed using ROBINS-I tool and observational study was assessed with relevant CASP checklists. Overall quality measurement was reported considering the all risk of bias domains for the particular research