PURPOSE: Managing access to care by means of the explicit prioritisation of patients could reduce the costs and consequences of waiting lists but raises concerns about equity in care provision. The purpose of this study was to analyse factors affecting doctors' and patients' judgements regarding the prioritisation of elective surgical patients. In addition, the participants' views on issues concerning the implementation of explicit prioritisation in clinical practice were assessed.

METHODS: Vignettes of patients with varicose veins, inguinal hernia, or gallstones were constructed using Conjoint Analysis. Each vignette comprised 4 attributes: physical symptoms, psychological distress, social limitations, and impairments in work. 257 patients, 101 surgeons, 95 occupational physicians, and 65 general practitioners each rated the urgency of 18 vignettes (randomly 2 of 3 disorders) for surgery on a VAS-scale. A multilevel linear regression model was built to analyse the priority judgements. Additionally, the participants' agreement with generic statements about prioritisation (e.g. fairness) were assessed.

RESULTS: The different groups showed large similarity when determining the urgency of the patient vignettes, yet concordance in the importance assigned to each factor was low between the individual members of each group (Kendall's Ws in each group <0.4). Grouped urgency ratings depended significantly on the type of disorder and on each factor in the vignettes (P<0.05). The highest weights were assigned to the physical symptoms (mean relative importance: 19.7%-44.3%) and impairments in work (24.3%-39.1 %). Most participants in each group endorsed the prioritisation of patients based on clinical need (75%-94%). Less agreement was found with prioritisation on the basis of the ability to benefit from treatment (28%-53%). Whereas most surgeons (73%) stated patient priority should be assessed by the individual physician, a majority of the other groups (55-62%) considered it best to assign priority based on agreed uniform criteria.

CONCLUSIONS: The high similarity in the priority judgements between different groups of stakeholders would suggest acceptance of an explicit priority scoring system for elective surgery based on the found mean weights assigned to the attributes. The large inter-individual variability in priority judgements combined with the strong preference for personal control in decisions about patient priority on behalf of the surgeons themselves, casts serious doubts on the feasibility of implementing explicit prioritisation fairly and uniformly in daily practice.