A rapid review of the effectiveness of innovations to support patients on elective surgical waiting lists
Authors: Okolie Chukwudi , Rodriguez Rocio , Wale Alesha , Hookway Amy , Shaw Hannah , Cooper Alison , Lewis Ruth , Law Rebecca-Jane , Gal Micaela , Greenwell Jane , Edwards Adrian 
Published: June 2022

Surgical waiting times have reached a record high, in particular with elective and non-emergency treatments being suspended or delayed during the COVID-19 pandemic. Prolonged waits for surgery can impact negatively on patients who may experience worse health outcomes, poor mental health, disease progression, or even death. Time spent waiting for surgery may be better utilised in preparing patients for surgery. This rapid review sought to identify innovations to support patients on surgical waiting lists to inform policy and strategy to address the elective surgical backlog in Wales.

The review is based on the findings of existing reviews with priority given to robust evidence synthesis using minimum standards (systematic search, study selection, quality assessment, and appropriate synthesis). The search dates for prioritised reviews ranged from 2014-2021.

Forty-eight systematic reviews were included. Most available evidence is derived from orthopaedic surgery reviews which may limit generalisability. The findings show benefits of exercise, education, smoking cessation, and psychological interventions for patients awaiting elective surgery. Policymakers, educators, and clinicians should consider recommending such interventions to be covered in curricula for health professionals.

Further research is required to understand how various patient subgroups respond to preoperative interventions, including those from underserved and minority ethnic groups, more deprived groups and those with lower educational attainments. Further research is also needed on social prescribing or other community-centred approaches.

It is unclear what impact the pandemic (and any associated restrictions) could have on the conduct or effectiveness of these interventions.

Rapid Review Details

Review conducted by

Public Health Wales

Review Team

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Dr Chukwudi Okolie

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Rocio Rodriguez

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Dr Alesha Wale

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Amy Hookway

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Hannah Shaw

Review submitted to the WCEC on

1st April 2022

Stakeholder consultation meeting

6th April 2022

Rapid Review report issued by the WCEC in

June 2022

WCEC Team

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Adrian Edwards, Alison Cooper, Ruth Lewis, Becki Law, Jane Greenwell involved in drafting Topline Summary and editing

This review should be cited as

RR00030. Wales COVID-19 Evidence Centre. Rapid review of the effectiveness of innovations to support patients on elective surgical waiting lists. April 2022.

This report can be downloaded here

https://healthandcareresearchwales.org/wales-covid-19-evidence-centre-report-library

Disclaimer

The views expressed in this publication are those of the authors, not necessarily Health and Care Research Wales. The WCEC and authors of this work declare that they have no conflict of interest.

TOPLINE SUMMARY

Our rapid reviews use a variation of the systematic review approach, abbreviating or omitting some components to generate the evidence to inform stakeholders promptly whilst maintaining attention to bias. They follow the methodological recommendations and minimum standards for conducting and reporting rapid reviews, including a structured protocol, systematic search, screening, data extraction, critical appraisal, and evidence synthesis to answer a specific question and identify key research gaps. They take 1-2 months, depending on the breadth and complexity of the research topic/ question(s), extent of the evidence base, and type of analysis required for synthesis.

Who is this summary for?

Health Boards and others involved in planning, monitoring, managing waiting lists for surgery.

Background / Aim of Rapid Review

Surgical waiting times have reached a record high, in particular with elective and non-emergency treatments being suspended or delayed during the COVID-19 pandemic. Prolonged waits for surgery can impact negatively on patients who may experience worse health outcomes, poor mental health, disease progression, or even death. Time spent waiting for surgery may be better utilised in preparing patients for surgery. This rapid review sought to identify innovations to support patients on surgical waiting lists to inform policy and strategy to address the elective surgical backlog in Wales. The review is based on the findings of existing reviews with priority given to robust evidence synthesis using minimum standards (systematic search, study selection, quality assessment, and appropriate synthesis).

Key Findings

Extent of the evidence base

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48 systematic reviews were included; 17 reviews were prioritised for inclusion in the narrative synthesis. A further 10 protocols of ongoing systematic reviews were included.

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Most reviews (n=23) focused on orthopaedic surgical procedures.

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Most reviews (n=31) focussed on exercise-based interventions. Other interventions were educational (n=6), psychological (n=2), smoking cessation (n=1), weight loss (n=1), and multicomponent interventions (n=7).

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There were limited data provided on socio-demographic characteristics of patients.

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No review evaluated the impact of the intervention on surgical treatment.

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No evidence relating to the use of social prescribing or other community-centred approaches to support surgical wait-listed patients was identified.

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No evidence was identified in the context of the current COVID-19 pandemic.

Recency of the evidence base

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The search dates for the prioritised reviews ranged from 2014-2021; these were conducted in 2020 (n=3) or 2021 (n=3) for six reviews.

Evidence of effectiveness

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Preoperative exercise interventions (n=9; 6 were orthopaedic) could help improve preoperative and postoperative outcomes such as pain, muscle strength and function, and reduced incidence of postoperative complications, in people awaiting elective surgery.

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Educational interventions (n=3; 1 was orthopaedic) were effective at improving knowledge in patients awaiting elective surgery. However, the evidence about these interventions improving pre- and postoperative pain and physical functioning in orthopaedic patients is limited. There were mixed findings for the effectiveness of preoperative educational interventions on psychological outcomes.

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Psychological interventions (n=2; 1 was orthopaedic) evidence is limited but indicates it may have a positive effect on anxiety and mental health components of quality of life postoperatively. The evidence in support of such interventions in reducing postoperative pain is inconclusive.

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Smoking cessation interventions (n=1) providing behavioural support and offering nicotine replacement therapy increased short-term smoking cessation and may reduce postoperative morbidity. Intensive preoperative smoking cessation interventions appear to reduce the incidence of postoperative complications, but not brief interventions.

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Multicomponent interventions (n=2; 1 was orthopaedic) consisting of both exercise and education components could shorten the length of hospital stay and improve postoperative pain, function, and muscle strength.

Best quality evidence

Three reviews were treated as high quality. Two evaluating exercise-based interventions (Fenton et al. 2021; Katsura et al. 2015) and one psychological preparation (Powell et al. 2016).

Policy Implications

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Most available evidence is derived from orthopaedic surgery reviews which may limit generalisability.

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These findings show benefits of exercise, education, smoking cessation, and psychological interventions for patients awaiting elective surgery. Policymakers, educators and clinicians should consider recommending such interventions to be covered in health professionals’ curricula.

▪

Further research is required to understand how various patient subgroups respond to preoperative interventions, including those from underserved and minority ethnic groups, more deprived groups and those with lower educational attainments.

▪

Further research is needed on social prescribing or other community-centred approaches.

▪

It is unclear what impact the pandemic (and any associated restrictions) could have on the conduct or effectiveness of these interventions.

Strength of Evidence

The primary studies included in the reviews were mainly randomised controlled trials, but most had small sample size, varied by surgical type, and often had issues regarding blinding.