Leach 2004.

Methods	Study design: re‐analysed ITS study Aim: to evaluate effects of implementation of 2 systems for managing generic outpatient waiting list on meeting national targets (3 months for routine outpatient appointment; 6 months for inpatient treatment) Timing: from June 2001 to November 2002; before intervention period: from June 2001 to mid September 2001; after intervention period: from mid September 2001 to November 2002 Data collection: data collected before and after the intervention; not further described
Participants	Providers: consultants and secretariat for integration of MRI appointment; number of providers not reported Participants: outpatients referred to neurosurgical services of Hope Hospital site in Salford for elective non‐complex spinal surgery (clear‐cut signs or symptoms of cervical or lumbar neural compromise, and no obvious underlying disease that might require spinal fixation, e.g. rheumatoid arthritis). Total number of participants not provided Participant baseline characteristics: Age: no information Gender: no information Ethnicity: no information Type of spinal surgery: no information Clinical problem: non‐complex (elective) spinal surgery Setting: all neurosurgical services within Greater Manchester Country: UK
Interventions	Type of intervention: intervention aimed at restructuring the referral process Intervention: managed generic (pooled) waiting lists for both initial outpatient appointments and dates for surgery + a computerised MRI booking system integrated with outpatient review appointments The managed generic outpatient waiting list begins with a consultant screening all new GP‐referred spinal cases to assess their suitability for inclusion in a pooled waiting list. Participants are then allocated to the next available appointment, irrespective of who the consultant might be. The managed generic surgical waiting list works through a similar process. When consultants list a patient for elective non‐complex spinal surgery, they indicate whether the patient should remain under their care or be entered onto a pooled waiting list. Pooled patients are then allocated dates for surgery sequentially vs Control: Each consultant managed his or her own waiting list Duration of intervention: approximately 15 months (mid September 2001‐November 2002)
Outcomes	Time from referral to first outpatient appointment Time from scan to outpatient review Time on waiting list for surgery Number of participants waiting < 9 months; between 9 and 18 months; longer than 18 months (outcomes included in the review
Notes	Waiting time thresholds appear arbitrary and not based on national recommendations for maximum waiting times as described in the introduction of the paper In our reanalysis, we considered as an intervention only the introduction of the generic waiting list for spinal surgery because data collection points related to implementation of a computerised MRI booking system integrated with outpatient review appointments in the preintervention period were insufficient to perform the analysis (< 3)
Risk of bias
Bias	Authors' judgement	Support for judgement
Intervention independent of other changes (ITS)?	Unclear risk	Quote: "To reduce waiting times, we employed two strategies. First, managed generic waiting lists were introduced for both initial outpatient appointments and dates for surgery. Subsequently the computerized MRI booking system was integrated with outpatient review appointments" The 2 interventions were implemented at different times; it is unclear whether there would be an impact on the waiting times on the surgical list. No information was given on other possible concurrent interventions
Analysed appropriately (ITS)?	Low risk	Reanalysed as ITS by review authors
Shape of the intervention effect pre‐specified (ITS)?	Low risk	Data reanalysed by review authors
Intervention unlikely to affect data collection (ITS)?	Unclear risk	No information given
Knowledge of the allocated interventions adequately prevented during the study (ITS)?	Low risk	Outcomes objective in nature; thus unlikely to be affected by a possible unblinded assessment
Incomplete outcome data addressed (attrition bias) (ITS)?	Unclear risk	No information given
Free of selective outcome reporting (reporting bias) (ITS)?	Unclear risk	Study protocol not available ‐ so outcomes reported in the paper cannot be checked against any prespecified outcomes
Free of other bias (ITS)?	Unclear risk	Only 7 out of 10 consultants participated. Not clear whether preintervention and/or postintervention data relate to waiting times for all 10 surgeons, or only for the 7 who agreed to the intervention. In addition, a problem was observed with discrepancies between numbers reported in the figures ‐ with a greater number of participants undergoing surgery than was reported among those referred by the GP