Priority Setting in Neurosurgery as Exemplified by an Everyday Challenge

Abstract

Background:The allocation of limited healthcare resources poses a constant challenge for clinicians. One everyday example is the prioritization of elective neurosurgical operating room (OR) time in circumstances where cancellations may be encountered. The bioethical framework, Accountability for Reasonableness (A4R) may inform such decisions by establishing conditions that should be met for ethically-justifiable priority setting.Objective:Here, we describe our experience in implementing A4R to guide decisions regarding elective OR prioritization.Methods:The four primary expectations of the A4R process are: (1) relevance, namely achieved by support for the process and criteria for decisions amongst all stakeholders; (2) publicity, satisfied by the effective communication of the results of the deliberation; (3) challengeability through a fair appeals process; and (4) Oversight of the process to ensure that opportunities for its improvement are available.Results:A4R may be applied to inform OR time prioritization, with benefits to patients, surgeons and the institution itself. We discuss various case-, patient-, and surgeon-related factors that may be incorporated into the decision-making process. Furthermore, we explore challenges encountered in the implementation of this process, including the need for timely neurosurgical decision-making and the presence of hospital-based power imbalances.Conclusion:The authors recommend the implementation of a fair, deliberative process to inform priority setting in neurosurgery, as demonstrated by the application of the A4R framework to allocate limited OR time.

Scoring System to Triage Patients for Spine Surgery in the Setting of Limited Resources: Application to the Coronavirus Disease 2019 (COVID-19) Pandemic and Beyond

“…Triage among nonemergent cases has been largely overlooked. One exception is the Accountability for Reasonableness (A4R) framework described by Ibrahim et al 32 to emphasize scheduling fairness and minimize operating room downtime at an academic center treating a mixture of emergent and elective cases. However, unlike the present scoring system, their framework was purely qualitative: triaging was performed by a single stakeholder without an obvious means by which surgical cases were ranked.…”

Bringing a Little Order to the Chaos: From the Operating Room, and Beyond

“…The authors of the article indicate that the use of the A4R framework has improved the functionality of the neurosurgical operating room when it comes to case prioritization by creating a fair, equitable and ethically justifiable process that holds individuals accountable to the standard of reasonableness (and one that thereby mitigates conflicts). 1 Though the article does not directly compare the situation pre and post A4R implementation, one has little reason to doubt the authors' conclusion. Indeed one could see the A4R framework applied to other elements of the neurosurgical frustration list presented.…”

“…As stressors on the system increase, the likelihood of problems increase. In the article by Ibrahim et al the issue of unexpected neurosurgical operating room cancellations is addressed -a situation that not infrequently can lead to chaos and frustration 1 . The authors adapt the A4R framework which has four primary expectations (or conditions), namely: 1. relevance, achieved by support for the process and criteria for decisions amongst all stakeholders; 2. publicity (or transparency), satisfied by the effective communication of the results of the deliberation; 3. challengeability (or revisability), accomplished through a fair appeals process; and, 4. oversight (or enforcement), ensuring all stakeholders that opportunities for improvement are available.…”