Personal views: Is rationing down under upside down?
Authors: Benjamin Bridgewater
Journal: BMJ (1998)

In January 1997 a report of a rationing system for coronary artery surgery (CABG) in New Zealand was published in the BMJ. This described the development of a priority scoring system for patients with angina whereby a panel of experts gave weightings to various factors thought to influence the benefit derived from surgery, such as the degree of coronary disease, severity of angina, and ability to work and live independently. 

These factors add together to give a priority score, with a maximum of 100. This system was piloted on a group of patients presenting for CABG, and the cost of providing surgery to patients above certain levels of clinical priority was calculated. The clinically desirable threshold was deemed to be 25, but with current levels of government funding it was decided by the minister of health that CABG could be provided only to patients scoring more than 35 points. 

In June 1997 I started a year’s sabbatical in cardiothoracic surgery in Green Lane Hospital in Auckland where I have watched this system in action. There are major differences in the way in which the service is provided. In Britain most consultant surgeons act independently to assess patients referred by the cardiologist in the outpatient clinic or on the wards and, once accepted for surgery, each consultant is responsible for managing his or her own waiting list according to clinical priorities, available operating resources, and purchaser contract targets. 

In New Zealand there is a more communal approach. Patients are assessed by the cardiologists, scored according to the priority scoring system mentioned above, given a predicted operative mortality, and presented at a weekly meeting at which both cardiologists and surgeons are present. Decisions on who is accepted and rejected for surgery are made by consensus. The surgeons rarely see the patients until the night before surgery. Discussions about risks, procedures, and benefits are between the cardiologist and patient in the first instance. It is unusual for high risk patients to be turned down for surgery at this meeting, and while predicted mortality is recorded in a structured way this is rarely mentioned. 

Some of the patients presented for discussion are those with coronary artery disease, which is significant and limiting but not of sufficient severity to score the threshold of 35 points. For example, a 50 year old man with class II angina (2 points), triple vessel disease with a 75% left anterior descending coronary artery stenosis (19 points), and a positive exercise test (12 points), who is not threatened but limited in his ability to work, care for dependants, or live independently (1 point) would score only 34 points on the original scoring system and so not usually be offered surgery. This patient would have a low perioperative mortality, a high chance of excellent postoperative quality of life, and would often have a survival advantage by undergoing surgical, rather than medical treatment. In Britain this patient would be offered surgery. In New Zealand his case can be presented at the meeting, but his acceptance for surgery by the group would go down as a precedent for future patients and is usually strongly resisted. 


The patient described above, who is refused surgery in the public sector in New Zealand, has several options. He or she can be referred for private treatment or placed on a review list. The outcome of patients on this list is not yet known. Some will undoubtedly suffer myocardial infarction and others will develop unstable angina and undergo surgery on an emergency or urgent basis with the associated increase in operative risk and cost. Most patients undergoing coronary artery surgery in Green Lane Hospital have unstable angina and a recent unpublished analysis of the 10% of patients with the lowest and highest risk of operative mortality during 1995 suggests that the high risk group has a 33% mortality and a 12% stroke rate and uses more resources than the low risk group, in which no mortality or strokes were seen. 


“The surgeons rarely see the patients until the night before surgery”



In Britain many patients undergoing surgery are urgent cases, and patients with strong indications for surgery are often left waiting for many months. But unlike New Zealand, very few low risk patients with a clinical indication for surgery are actually refused an operation. However it is my impression that surgeons in Britain are more willing to refuse the high risk cases with less predictable outcomes. 

New Zealand has made an impressive attempt to ration CABG surgery and focus a set budget on patients with specific indications, decided not by individual preference but by national guidelines and local consensus. As yet they have no guidelines for refusing to accept the high risk cases. By doing so they have rationed out many low risk patients with categorical clinical indications for surgery, while rationing in many high risk patients with strong indications but high perioperative mortality, morbidity, and economic costs with inferior long term quality of life. 

Denying surgery to high risk patients who may well die without surgery in favour of lower risk cases with more predictably beneficial outcome is a difficult moral issue and one which needs to be faced in all healthcare systems with limited resources. But there are certainly many precedents for directing limited available resources to the best possible patients, such as setting tight admission criteria for admission to transplant waiting lists. 

While the New Zealand rationing system is going some way to contain costs, it seems to be doing so at the expense of those patients with known benefits at reasonable expense.