ANZ J. Surg.

2003; 73: 839842

ORIGINAL ARTICLE
ORIGINAL ARTICLE

CLINICAL CATEGORIZATION FOR ELECTIVE SURGERY IN VICTORIA

COLIN RUSSELL,* MAREE ROBERTS, TIMOTHY G. WILLIAMSON, JANE MCKERCHER, SIMON E. JOLLY
AND JOHN MCNEIL

*Peninsula Health and Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University,
Monash Medical Centre and Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health
Sciences, Monash University, Alfred Hospital and Department of Human Services, Melbourne, Victoria, Australia
Aim: The aim of the present paper was to assess trends in clinicians utilization of urgency categories for elective surgery.
Methods: The present paper reviews the additions to the Victorian elective surgery waiting list for hip replacement and prostatectomy as recorded by the Elective Surgery Information System database. Review of general trends in utilization over two separate
12 month periods were undertaken.
Results: There is inconsistency in categorization of patients referred to the waiting list for hip joint replacement and prostatectomy. An increasing trend to categorize patients as semi-urgent (category 2) in preference to non-urgent (category 3) emerged over
this period (category creep). Semi-urgent cases might be competing for access within the category 2 band with less urgent cases.
Conclusions: There seems to be an increasing imbalance between demand for and availability of elective surgery for lower
urgency elective surgical procedures. This imbalance, characterized by lengthening waiting times, means that not all patients will
receive treatment within the clinically recommended waiting times. The variable approach to categorization of urgency suggests that
the process lacks objectivity and consensus. Simple clinical tools to assist prioritization are currently being evaluated in Victoria
(Australia) and other countries.
Key words: elective surgical procedure, waiting list.
Abbreviations: Cat. 1, category 1; cat. 2, category 2; cat. 3, category 3; DHS, Department of Human Services; ESIS, Elective

Surgery Information System; WCWL, Western Canada Waiting List Project.

INTRODUCTION
Waiting lists, or more precisely, waiting times, for elective
surgery are a contentious issue. Their magnitude is dependent on
the balance between the demand for surgical services and their
availability. The existence of waiting lists implies a demand that
exceeds the capacity or willingness to supply. Prolonged waiting
times are typically concentrated among the procedures where
treatment can be tolerably deferred or those that are seen as relatively discretionary.
Waiting lists do provide hospitals with the means to achieve
full utilization of their facilities by creating a pool of patients,
which smoothes fluctuating demand.1 In a private market system,
the demand denoted by a substantial waiting list would generally
lead to an increase in service provision or in the price charged for
these services. In the current public sector model, incentives such
as these are absent and there is, therefore, less opportunity to
regulate supply or demand. However, waiting lists are generally a
politically sensitive issue and any substantial increase in waiting
times can lead to the provision or redirection of resources.

Equity of access is a fundamental requirement of any publicly

funded health-care system. The existence of waiting lists makes it
necessary to institute mechanisms to prioritize access to surgical
services in a way that is both transparent and fair. This issue has
recently been addressed by The Council of Europe, which has
defined principles for managing access to elective surgery.2
These principles include objectivity, equity, reproducibility and
transparency in selection of patients for treatment.
In Victoria a system of categorization of clinical urgency for
elective surgery has existed for some years but its relative merits
and its ability to meet the desired criteria (see above) have not
been formally assessed. We have used the Victorian waiting list
database (see below) to examine trends in Victorian waiting lists
and to study the utilization of urgency categories for two common
elective surgical procedures with long waiting times joint
replacement and prostatectomy. The findings have been used to
support a case for additional research into ways to prioritize
patients awaiting surgical procedures

METHODS
Background to current prioritization system

Associate Professor Colin Russell is chairman of the Victorian Advisory

Committee on Access for Elective Surgery (ACAES), an advisory committee of
the Department of Human Services (DHS). The views expressed in this paper are
personal and not necessarily those of the Department of Human Services.
C. Russell MS, FRACS; M. Roberts MA (Hons) BA; T. G. Williamson
BSc (Hons), PhD; J. McKercher; S. E. Jolly PhD; J. McNeil PhD, FRACP.
Correspondence: Associate Professor Colin Russell, Director of Surgery,
Peninsula Health, Hastings Road, Frankston, Vic. 3199, Australia.
Email: crussell@phen.vic.gov.au
Accepted for publication 28 May 2003.

In 1991 the Health Department of Victoria, in consultation with

its clinical advisory group3 introduced a clinical urgency categorization system for elective surgery. The system, shown below,
established clinically desirable waiting times (urgency profiles)
for each of the three categories and has been in use across the
spectrum of elective surgery for 10 years.
Category 1 (Cat. 1) Urgent
Admission within 30 days is desirable for a condition that has the
potential to deteriorate quickly to the point that it might become
an emergency.

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RUSSELL ET AL.

Category 2 (Cat. 2) Semi-urgent

Admission within 90 days is desirable for a condition causing
some pain, dysfunction or disability but which is not likely to
deteriorate quickly or become an emergency.
Category 3 (Cat. 3) Non-urgent
Admission at some time in the future is acceptable for a condition
causing minimal or no pain, dysfunction or disability, which is
unlikely to deteriorate quickly and that does not have the potential to become an emergency.
The above are now national data definitions. Perceived urgency
of need for care has been distributed among three bands, each with
a recommended waiting time. With the exception of New South
Wales, which has a fourth category (patients requiring surgery
within 7 days), all other states and territories use this system.

Data extraction
The utilization of urgency categories for two common elective
surgical procedures with long waiting times, joint replacement
and prostatectomy, was studied. The data presented below have
been extracted from the ESIS files. Information was sought concerning the total numbers of patients awaiting elective surgery
and trends in numbers and waiting times within the three waiting
list categories. Information on the urgency categories of patients
at the time of referral for total hip replacement or prostatectomy
to the waiting lists of specific hospitals was extracted.
Advice from one of the authors (J McNeil) chairman of
research and ethics committee of a major health service confirmed that since identifiable information was not used, Ethics
Committee endorsement of the project was not necessary.

Assignment to prioritization categories

RESULTS

The appropriate urgency category is assessed by the referring

specialist at the time a patient is referred to the waiting list. It is a
required field that must be documented before a patient is
accepted onto the hospital waiting list. Since 1998 it has been a
requirement for hospitals to submit data, on a monthly basis, to
the Elective Surgery Information System (ESIS). This is a central
database, maintained by the Victorian Department of Human
Services (DHS). The DHS provides strong financial incentives to
ensure that no cat. 1 patients wait longer than 30 days for treatment and publishes quarterly reports on trends in waiting list
numbers, waiting times, categorization and elective surgery
throughput from this database.4

Figure 1 shows the trend in the total number of patients awaiting

admission for elective surgery in Victoria between 1 July 1998
and 30 June 2001. Over this time waiting list numbers have
increased and reached a peak of just over 44 000 in January 2001.
However, in the last 6 months of 2001 they declined to below
42 000.
Table 1 shows the number of patients admitted from the elective
surgery waiting list in Victoria during the 12 month periods of
1998 and 1999 and 2000 and 2001 and their waiting list categories.
Between these two periods the total annual admissions for elective
surgery declined by 13 652 (11%). The throughput of elective
patients assigned to cat. 1 actually increased by 3.6% but the percentage of cat. 2 and 3 patients admitted fell by 2.7% and 6.3%,
respectively. Almost half the patients admitted for surgery from the
elective waiting list in 20002001 had been assigned to cat. 2.
Table 2 shows the number of patients added to each of the
three waiting list categories during the 12 month periods of 1998
and 1999 and 2000 and 2001. The most evident features are the
10.1% increase in the number of patients assigned to cat. 2 and
the 11.8% decrease in assignment to cat. 3. The percentage of
patients allocated to cat. 1 showed a more minor change. Average
waiting times for surgery for patients in cat. 2 and 3 also
increased over this time (Fig. 2) in keeping with the decrease in
the total numbers admitted for elective surgery.
Figures 3 and 4 show the distribution of urgency categories for
patients placed on the waiting lists of metropolitan and major
rural hospitals for two specific procedures total hip replacement
and prostatectomy between 1 July 2000 and 30 June 2001.
These varied greatly among the 19 hospitals. Clinicians from hospital 1 in Fig. 3 (at the top of the chart) categorized >20% of their
patients in need of total hip replacement as cat. 1, whereas clinicians from hospital 19 (at the bottom of the chart) placed no
patients in this category. The allocation of patients to cats 2 and 3
also show marked variation among hospitals.

Fig. 1. Total number of patients waiting for elective surgery from

1 July 1998 to 30 June 2001.

Table 1. Number of patients and percentage by category admitted from the elective surgery waiting list in two separate years
Urgency category
1
2
3
Total

No. (% of total) patients admitted from waiting list

19981999
20002001
20 253 (16.3%)
56 725 (45.7%)
47 059 (38%)
124 037

21 962 (19.9%)
53 450 (48.4%)
34 973 (31.7%)
110 385

Change in patient numbers

(change in %)
+1709 (+3.6%)
3275 (2.7%)
12 086 (6.3%)
13 652

ASSESSING URGENCY FOR CARE

841

The categorization profile for patients awaiting prostatectomy

(Fig. 4) shows a similar variation.
Figures 3 and 4 also demonstrate that these trends in categorization are not hospital specific, with the distribution of cat. 1,
2 and 3 varying by procedure, rather than suggesting a constant
trend within any specific hospital.

DISCUSSION
The data presented were derived from an information system
(ESIS) that facilitates close monitoring of trends in access to elective surgery in Victoria. The results have shown an increase in
waiting list numbers, particularly among patients assigned to cat.
2. Numbers waiting in cat. 3 have also increased to a lesser extent
and waiting times for both categories have increased. The data
suggest a major category creep, with an increasing proportion of
patients assigned by their clinicians to cat. 2 rather than cat. 3.
The data presented also suggest that clinicians from different
hospitals are inconsistent in their allocation of clinical urgency
categories, at least in the two major categories for elective
surgery examined in the present study. The burden of disease
managed by these hospitals is unlikely to be sufficiently different
to account for the variations in categorization observed. The differences probably result from variation in the clinicians approach
to, and interpretation of, the current categorization system. This
variability has made it easy for category creep to occur over time.
Given the relatively vague distinction between cats 2 and 3 it is
not surprising that clinicians are increasingly reducing the pro-

portion of patients they allocate to cat. 3; considering that the

waiting time for patients in cat. 3 now averages approximately
10 months (rather than 3 months for cat. 2). The resulting tendency to classify more patients into cat. 2 rather than cat. 3 might
cause waiting times for true semi-urgent cases, within the cat. 2
band, to increase beyond acceptable limits. Ninety-nine per cent
of cat. 1 patients are admitted within the target (30 days),4 suggesting that the system does ensure timely treatment for those
perceived to have the most urgent need for care.
Variations in urgency categorization are also evident on a
national scale.5 The allocation of patients to urgency cat. 1 varies
from 16.3% in Victoria to 43.6% in Tasmania. Differences in
severity of disease within these states is again unlikely to explain
this variation and suggests that the difference lies in the interpretation and application of the national data definitions among
individual clinicians.
The relationship between severity of illness and waiting time
for elective surgery has previously been shown to be tenuous.68
A study conducted in an area health service in New South Wales
has shown that although waiting time was strongly associated
with the urgency rating given by the surgeon7 a number of other
factors surgical specialty, health insurance status and employment status appeared to exert an additional and independent
influence on waiting time. Informal guidelines for prioritizing
urgency of surgery have existed for some years but none has
gained national acceptance.
The problems associated with long waiting lists and their management have been observed in many countries with publicly

Table 2. Number and percentage of patients by category added to elective surgery waiting list during one full year 19981999 and 20002001
Urgency category
1
2
3
Total

No. (% of total) patients added to elective surgery waiting list

1 July 199830 June 1999
1 July 200030 June 2001
29 447 (5.7%)
190 172 (36.5%)
300 793 (57.8%)
520 412

Fig. 2. Average waiting times for cat. 2 and 3 patients between July
1998 and May 2001. , cat. 2; , cat. 3.

34 647 (7.4%)
216 581 (46.6%)
213 847 (46.0%)
465 075

Change in patient numbers

(change in %)
5200 (+1.7%)
26 409 (+10.1%)
86 946 (11.8%)
55 337

Fig. 3. Distribution between urgency categories among metropolitan and major rural hospitals of patients placed on the waiting list
for total hip replacement between 1 July 2000 and 30 June 2001. ,
cat. 1; , cat. 2; , cat. 3.

842

Fig. 4. Distribution between urgency categories among metropolitan and major rural hospitals of patients placed on the waiting list
for prostatectomy between 1 July 2000 and 30 June 2001. , cat. 1;
, cat. 2; , cat. 3.

funded health services.9 Equity of access to health care is a major

plank of the Australian Health Care Agreement and other public
health systems. Where allocated resources do not meet demand for
services, the goal should be provision of care to those with the most
urgent needs and ability to benefit. The present study suggests
that the current Victorian (and Australian) urgency categorization
system for elective surgery might be unable to recognize this goal.
Some countries, particularly New Zealand and Canada, have
seen benefit in developing appropriate guidelines and priority
scoring systems in an attempt to make prioritization more consistent and reproducible.1013 Experience to date suggests only
limited success with these approaches.14 However, as experience
increases, it is hoped that refinement of the methodology will
create a more robust and useful system of prioritization.
The ability to categorize urgency for specific clinical conditions,
such as joint replacement, prostatectomy and cataract removal, is
an important first step. It is likely to prove a more readily attainable
goal than attempting categorization across the entire spectrum of
elective surgery. However, it will become necessary to attempt a
more global approach to prioritization, if only to allow a rational
allocation of resources among different clinical specialty areas.
Preliminary validation studies by the Western Canada Waiting
List Project (WCWL)11 of a clinical categorization tool for prioritizing urgency for joint replacement have been encouraging. In a
collaborative project with local clinicians we have made some
necessary but minimal adaptations to this WCWL categorization
tool. A study to test and validate this revised tool under local
conditions is near completion. Using the same collaborative
approach we have developed a categorization tool for patients
awaiting prostatectomy. This is currently being evaluated using
similar methodology. The results of these studies and a review of
the current status of clinical categorization will be published separately. We are also investigating the attributes of, and canvassing opinion on, replacing the current three urgency bands with a
four category system.
In summary this study has shown:
An inconsistent approach to categorization of urgency
among specialists for individual conditions/procedures (joint
replacement and prostatectomy)
An increasing trend to categorize patients as semi-urgent
(cat. 2) in preference to non-urgent (cat. 3) is emerging (category

RUSSELL ET AL.

creep). Semi-urgent cases might be competing for access within

the cat. 2 band with non-urgent cases.
The data also indicate an increasing imbalance between demand
for, and availability of access to elective surgery for lower urgency
elective procedures. This imbalance, characterized by lengthening
waiting times, means that not all patients will receive treatment
within the clinically recommended waiting times. The variable
approach to categorization of urgency might suggest that referring
specialists are failing to meet the desired criteria of objectivity,
equity, reproducibility and transparency in the management of
demand for elective surgery. Part of the approach taken to resolve
this issue will involve the use of more precise, reproducible and
valid instruments to assist prioritization, such as those that are currently being evaluated in Victoria and in other countries.

ACKNOWLEDGEMENTS
The authors wish to acknowledge support from the following:
the Victorian Department of Human Services for the provision of
data and support for Colin Russell during his recent sabbatical
leave and the Advisory Committee on Access for Surgery, whose
search for trends within available waiting list data has brought to
light the problems with the current categorization system.

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