Patient and provider perspective with the use of a central intake system (CIS) for surgical waitlist management: a systematic review

Abstract

Objective

Our study aimed to summarise and reflect on current evidence around patient and surgeon perspectives regarding the use of a central intake system (CIS) as a strategy for managing surgical waitlists.

Search strategy

A systematic review was conducted. Searches were performed on 9 October 2023. The strategies used key words such as ‘central intake’, ‘surgery’ and ‘experience’. Medical and the Web of Science core databases were searched.

Inclusion criteria

Titles and abstracts were assessed by two independent reviewers. Studies were included if: the study population was adult (age >18), and patients were referred for non-emergency surgery assessment.

Data extraction

Data were independently extracted by two reviewers using a standardised form. The Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative Research was used to assess study quality. Of 2805 studies identified, nine were included with a moderate to high confidence of evidence. Through thematic analysis, four patient and five surgeon themes were identified, with a further two common themes (although conceptualised differently).

Results

Patients value CISs for their potential to create an equitable referral process and clearer timelines, yet they emphasise the importance of preserving autonomy and personalised care by maintaining the option to choose their surgeon. Surgeons recognise the operational benefits of CISs in streamlining referrals and reducing wait times, but also caution that adequate resources, strong leadership and careful case selection are critical to sustain quality and engagement.

Conclusions

These findings highlight the complex balance required to successfully implement CISs. The system-level gains in access and coordination must be carefully aligned with patient-centred values such as choice and trust and supported by organisational culture shifts and leadership commitment. Importantly, the study identifies gaps in end-user involvement and decision-making power that should be addressed to enhance acceptability and effectiveness.

Future actions should consider a framework that incorporates clear governance with continued pilot programmes that include evaluation of patient satisfaction, quantitative and qualitative clinical outcomes, and impact on equity. Additionally, targeted strategies are needed to accommodate complex or specialised cases that may not fit the central intake model. Through careful implementation and continuous stakeholder engagement, central intake models have the potential to meaningfully improve surgical waitlist management while respecting the needs and preferences of both patients and surgeons.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Thorough summary of existing research on a specific topic.

• The methodology is transparent and reproducible.

• Qualitative data is difficult to evaluate and interpret.

• There is a lack of studies published relevant to the research question.

• The included studies vary in methodologies and populations, leading to possible heterogeneity.

Background/Introduction

Wait times for non-emergency surgical care remain a persistent concern in the Canadian healthcare system. National benchmarks for priority procedures were established in 2005, setting standards adopted by federal, provincial and territorial governments.¹ For hip and knee replacement, the benchmark wait time from referral to specialist was 3 months with the patient undergoing treatment within 6 months. In 2019–2020, the national average for patients receiving a hip or knee replacement within this benchmark was 72%, with significant variability among provinces.¹,³ The management of wait times involves both supply- and demand-side policy interventions in decentralised health systems like Canada’s.^{12 4},¹¹ Examples from the demand side include population health interventions, strong primary care, explicit clinical triage guidelines and prioritisation.^{12 4},¹³ The supply side includes funding additional surgeries, introducing activity-based funding models, adding additional providers and enhancing waitlist management.^{23 5 7},^{12 14}

The central intake system (CIS) is a waitlist management approach, based on queuing theory and designed to streamline the referral and triage process.¹,^{1012 13} CISs enhance service access in healthcare systems by placing all patients in a single, shared queue across multiple surgeons, where they are screened, triaged and referred to the appropriate service or healthcare professional.¹,^{1012 13} In the literature, CIS can also be referred to as a central referral system and pooled referral system. CIS models have been implemented in several Canadian provinces, including the Winnipeg Central Intake System, British Columbia Surgical Strategy, Nova Scotia Hip and Knee Action Plan, and Saskatchewan Surgical Initiative.¹,^{1012 13}

CISs are effective at managing wait times¹⁰¹⁵,²² ; however, there is limited understanding of the perspectives of both patients and surgeons. Since the support of both groups is crucial for the success of CISs, it is essential to gain deeper insight into their views. This systematic review analyses both the patients’ and surgeons’ perspectives regarding the introduction of CISs as a solution to waitlist management.

Search strategy

A systematic review was conducted following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines.^{23 24}

An experienced medical information specialist developed the search strategies, and a second senior information specialist peer reviewed the MEDLINE strategy using the Peer Review of Electronic Search Strategies (PRESS) Checklist.²⁵ We searched Ovid MEDLINE ALL, Embase, APA PsycInfo, CINAHL on Ebsco and the Web of Science core databases. All searches were completed on 9 October 2023. The strategies used a combination of controlled vocabulary (eg, ‘Waiting Lists’, ‘Surgical Procedures, Operative’, ‘Focus Groups’) and keywords (eg, ‘central intake’, ‘surgery’, ‘experience’). Vocabulary and syntax were adjusted across the databases, and where possible, animal-only records and conference abstracts prior to 2021 were excluded. No date restrictions were applied to the studies. Only articles in French and English were included, and additional articles were identified through hand-searching the reference lists of included studies. No grey literature search was undertaken. Details of the search strategy can be found in online supplemental appednix A. Covidence was used for the review.

Inclusion criteria

The study population was adult (age >18) patients, referred for non-emergency surgery assessment (surgical procedures with the ability to be scheduled in advance and do not require immediate medical attention). The intervention was non-emergency surgical referral systems with centralised intake, or pooled referral systems. Studies were included if they reported patient or surgeon experience or perspective. Only studies published in English or French were included. Details of the inclusion criteria can be found in online supplemental appednix B.

Calibration was achieved by screening sequential sets of 50 abstracts until full agreement (100%) was reached among three independent reviewers (LK, BOA and FC). Once consensus was established, the same screening criteria were applied by LK and BOA to all remaining titles, abstracts and full texts in duplicate. Prior to full-text screening, an additional calibration exercise was conducted using sequential sets of five articles until 100% agreement was again achieved. Full texts that were included by both reviewers were retained in the final data set. Any disagreements were resolved by consulting the third independent reviewer (FC).

Data extraction, quality assessment and analysis

Two reviewers (LK and BOA) independently extracted data using a standardised data extraction form (see online supplemental appendix C). Common themes were identified and grouped. These themes were then reviewed by two independent reviewers (FC and LK) to ensure consensus.

Confidence (ie, quality) was assessed for each review using the Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual); this is conceptually like other GRADE tools but is employed in qualitative evidence syntheses.²⁶ All criteria were evaluated using a minor, moderate or high scoring system and then combined to form a GRADE-CERQual rank of confidence.^{27 28} The approach was conducted, summarised and reviewed by two independent reviewers (BA and LK), with a summary of the GRADE-CERQual findings shown in onlinesupplemental appendices D E.

Only qualitative studies were included in our final dataset. Had a quantitative study been eligible for inclusion, the Risk Of Bias In Non-randomised Studies (ROBINS) 2 tool for assessing risk of bias in non-randomised studies, in accordance with Cochrane guidelines.

Patient and public involvement

Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

Results

2805 studies were identified, 14 duplicates were removed, leaving 2791 for the initial ‘title and abstract’ screening. 12 studies were included in the ‘full text review’ and of these, eight studies met the inclusion criteria (figure 1). Additional screening was conducted using the reference list from each of the eight studies, resulting in one additional study being identified that met the inclusion criteria. Nine studies formed the final dataset.²⁹

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram.

All nine studies employed qualitative methodologies, as outlined in table 1. The confidence in evidence for each theme was assessed using the CERQual approach and rated as moderate to high (see onlinesupplemental appendices D E). Studies were conducted in Canada, UK, Sweden, Norway, New Zealand, Australia, Italy and the USA. The studies were published from 2003 to 2022, and although only patient and surgeon perspectives were captured in our systematic review, participants included allied healthcare professionals and administrators. The studies used a range of methodological approaches, including inductive synthesis, case studies, commentaries, interpretive description, surveys and interviews.

Table 1. Characteristics of included studies (author, year, country, study type, aata collection methods, data analysis, intervention, participants and setting, phenomena of interest, and authors’ conclusion).

Author Year Country	Study type	Data collection Methods Data analysis	Intervention	Participants and setting	Phenomena of interest	Authors’ conclusion
Damani 2016 Canada	Mixed-methods case study approach (qualitative interviews and administrative data analysis)	Conducted policy and round table meetings to determine evidence-informed policy directions. Thematic analysis	The CIS was a streamlined system crafted to enhance service delivery by consolidating waiting lists and available providers. In this model, individuals seeking healthcare services enter through a central point-of-entry, referred to as centralised intake. The fundamental principle of the CIS was to efficiently direct patients to the first-available provider.	22 participants attended from the five stakeholder groups that were targeted: patients (n=4), family physicians (n=2), orthopaedic surgeons (n=1), surgical office assistants (n=2), the WCIS team members (n=13) and members of our national research team (n=10).	Effectiveness of the WCIS (CIS in Winnipeg, Manitoba) in enhancing patient accessibility to hip and knee replacement surgeries.	Interest in centralised intake for clinical services exists across Manitoba, but further evaluation of CISs is necessary. A deliberative policy dialogue process holds promise for inclusive discussions, allowing for the development of effective, evidence-informed policies.
Damani 2019 Canada	Mixed-methods case study	Each WCIS project team member was contacted by email or telephone and interviewed one-on-one by telephone twice; interviews ranged between 30 and 90 min and were conducted by ZD. Audio-recorded and transcribed all interviews verbatim. Thematic analysis	Use of CISs allowing patients to see the next-available provider for hip and knee replacement surgery.	13 participants, including processing engineers, project sponsors, waiting list coordinators, managers, the medical director and policymakers from the WRHA and Manitoba Health, were invited and willingly agreed to take part.	Assess the successes, challenges and unanticipated consequences arising from the design and implementation process of wait time management strategies.	While the implementation was successful, valuable insights were gained regarding change management. Incorporating and applying these lessons and critical success factors can mitigate unforeseen consequences, enhance adoption and contribute to the success of new care models.
Goldthorpe 2018 UK	Qualitative exploration of implementation using interviews	Views were sought from stakeholders (dentists, hospital staff, commissioners and patients) at various timepoints over 3 years during and after implementation using Semi-structured interviews. Thematic analysis	Development of a primary care oral surgery service combined with an electronic referral management (referral form with mandatory clinical fields) and clinical triage system.	Surgeons (n): a total of 28 interview transcriptions in the analysis. Patients (n): 14 participants were female and 14 were male. The average age of participants was 60 years and 3 months. 9 participants were treated at the advanced primary care service, 4 at the foundation trust hospital, 3 at the dental hospital and 12 participants were treated at the district general hospital.	Qualitative exploration of implementation of a new intervention (specialist primary care oral surgery service combined with an electronic referral management and triage system) to gain insight into how these challenges have manifested and been addressed.	The successful implementation of electronic referral management, coupled with a primary care advanced service for oral surgery, was achieved in a specific region of the UK. The assessed service model has the potential for expansion across a broader geographical area and can contribute to demand management in various other specialist services.
Keenan 2017 UK, Ireland	Mixed-method conference abstract	Survey Thematic analysis	Pooled in-patient and day case surgical waiting list.	Surgeons (n): 0 Patients (n): 79	Evaluate a national pilot project on waitlist management using pooled inpatient and day case surgical waitlists.	The study found that successful pilot implementation of a new healthcare model was due to factors like openness, teamwork and leadership. Barriers included a lack of dedicated administrative staffing and clinician involvement from one hospital. To ensure sustainability and scalability, recommendations include a prescreening questionnaire and a single point of contact at each hospital. Challenges such as limited resources and capacity were identified as constraints for further implementation.
Lopatina 2017 Canada, United Kingdom (UK), Sweden, New Zealand, Norway, Australia, Italy, US	Inductive qualitative synthesis	Focus group reflection	Roadmap for healthcare decision-makers, managers, physicians and researchers to guide implementation and management of successful and sustainable CISs.	Surgeons (n): 7 clinicians. Patients (n): 4 patient representatives.	Roadmap for healthcare decision-makers, managers, physicians and researchers to guide implementation and management of successful and sustainable CISs.	The themes underscore the promise of CISs in tackling long waiting times for initial assessments. Success hinges on ongoing performance measurement and improvement. The CIS roadmap, designed for clinicians, decision-makers, managers and researchers, serves as a dynamic guide, evolving as we learn more about implementing and managing sustainable CISs.
Ramchandani 2003 UK	Perspective	Interviews	Pooled waiting list with patients treated in turn by the consultant available in relation to cataract surgery.	Surgeons (n): 776 consultant ophthalmologists in the UK, 752 still practising, this yielded 479 completed replies (64%). Patients (n): 85 patients	Pooled waiting lists—whereby patients are treated in turn by the first available surgeon.	Findings on cataract surgery may be applicable to other routine operations such as hip replacement, herniorrhaphy and prostatectomy.
Shapiro 2022 Canada	Interpretive description and qualitative approach	Interviews	An CIS utility in managing the elective surgery backlog in Ontario using the implementation of an equitable and efficient CIS approach.	Surgeons (n): 10	Views of health system leaders on the role of CISs in managing the elective surgery backlog.	Participants express a belief in the potential of CISs to enhance quality and minimise variability in wait times, particularly when tailored to address local needs and supported by champions. Considering the unique opportunity for transformational changes in the postpandemic world, clinical leaders and policymakers are encouraged to explore the adoption of CISs as a strategic approach to effectively manage surgical backlogs in their respective local authorities.
Urbach 2020 Canada	Commentary	–	Employing a CIS to tackle wait time issues by establishing a unified queue that directs patients to the next available provider based on acuity and priority. This approach incorporates team-based care, where a collaborative group of providers collectively manages the surgical care of each patient. This means that the initial surgeon a patient encounters may not necessarily perform the operation; instead, another equally skilled team member, familiar with the case particulars, may conduct the procedure.	–	Adoption of a CIS or team-based approach, to aid in the Canadian recovery from previous surgery backlog that has been amplified by the COVID-19 pandemic.	Adopting CISs and team-based care is seen as the fairest and most patient-centred approach for surgeons to provide care and maintain their skills. Surgeons are urged to collaborate with health system leaders, hospital administrators and policymakers to implement these models as part of a surgery recovery plan from the COVID-19 pandemic. This presents an opportunity for a broader transformation of surgical services towards a sustainable and ethical health system in Canada.
Zee 2019 Canada	Qualitative case study	Focus group Survey Thematic analysis	A pooled referral system for surgery of patients’ attitudes toward a pooled waitlist for urogynaecology and pelvic reconstructive surgical procedures.	Surgeons (n): 1 of 5 urogynaecologists Patients (n): 176 patients were surveyed.	Patients’ attitudes towards a pooled waitlist for urogynaecology and pelvic reconstructive surgical procedures.	Urogynaecology patients generally have low acceptance of pooled surgical waitlists, regardless of disease severity. Only 34% were open to this option, with 86% strongly preferring surgery performed by their own care provider. This contrasts with findings in other surgical fields. Understanding patients' concerns and negative perceptions of surgical waitlists is crucial to maintain patient comfort and satisfaction if this strategy is adopted. Notably, women aged 65 years and above were less likely to accept a pooled surgical waitlist option.

CIS, central intake system; WCIS, Winnipeg Central Intake System; WRHA, Winnpeg Regional Health Authority.

Emergent themes were identified through thematic analysis and deductive reasoning by LK, BOA and FC. The analysis revealed four patient themes and five surgeon themes. Additionally, two common themes were identified across both groups, although they were conceptualised differently by patients and surgeons figure 2.

Figure 2. Summary of emergent themes identified for patients and providers' experience with the use of a CIS for non-emergency surgery.

Patient themes

Patients identified transparency as a key benefit of implementing a CIS. Transparency provided visibility into the referral process and clearer timelines from referral to surgical procedure. Patients indicated they would be more willing to switch surgeons or see the next available provider if it resulted in shorter wait times—provided they received adequate reassurance and a clear explanation.¹⁰

Concerns patients expressed with the introduction of a CIS were Electronic System (ES) and Information Technology (IT), flexibility, and trust and complexity. Concerns with ES and IT included the electronic process, structure and performance, with patients agreeing that ES components should be visible, but with careful consideration into what and how information is reported beyond the patient.¹⁵ There was also a lack of understanding around IT, as patients perceived referrals took longer to complete.¹⁷

Patients expressed concern over the lack of flexibility within a CIS. Flexibility was defined as having multiple pathways to select a surgeon, while still ‘giving patients the freedom to decide whether to wait for a surgeon or receive timely care’.²⁰ Trust presented a similar concern compared with flexibility for patients, with concerns that CISs eliminate a patient’s ability to choose a surgeon. CISs were viewed as a universal application, leading to depersonalisation, decreased accountability, reduced appropriateness of referrals and a variability in quality between providers.^{10 15} Complexity was grouped with trust as the two are codependent. Surgeries are often complex, with other specialities outside of surgery involved. Concern was expressed over CISs maintaining access to multiple providers in a variety of care settings.^{10 15}

Surgeon themes

CIS benefits identified by surgeons were efficiency and teamwork. Surgeons defined CIS efficiency as the speed and ability to triage referrals, patient consults and conduct surgery. There was an increase in referral screening and allocation based on the surgeon’s capacity to accept referrals, which led to reduced overall wait times between participants.¹⁶ Surgeries were also conducted faster, resulting in shorter wait times for patients in chronic pain. ‘CISs make elective surgical care more efficient and also decrease the indirect costs of care by lowering costs associated with patients not being in pain’.²⁰

Surgeons identified the teamwork approach enabled by the CIS as a key benefit. CISs facilitated a team-based model of care that supported shared responsibility for patient outcomes and offered tangible improvements to surgeons’ work-life balance.²⁰ ‘Care could be elevated to a system level, where all providers work together for the best care possible’.¹⁵ A CIS also encouraged the application of prior learning, mutual education, collective analysis and discussion.¹⁰

Surgeons expressed concerns over infrastructure, quality and design, leadership and communication, and a streamlined process. Surgeons defined infrastructure as a CIS’s physical and human resources capacity. Surgeons felt that ‘improving capacity is necessary to shorten wait times’, as the current system does not easily adjust to large volumes.²⁰ Additionally, ‘lack of infrastructural and informational resources, and administrative and clinical capacity, (were also identified) as constraining factors’.¹⁸

Surgeons viewed leadership as a critical component in the successful introduction of CISs. Leadership was defined as the capacity to influence and guide the development, implementation and sustainability of CISs. Effective change management and cultural transformation demand strong leadership, which is often challenging due to the fragmented nature of the current system. As one participant noted, ‘physician leadership is needed to champion CISs, from someone who is a trusted and recognised senior opinion leader in their field’.²⁰ Sustained success also requires engagement from all stakeholders, including patients and providers, along with clearly defined metrics to overcome system silos and maintain consistent quality.^{14 20}

Surgeries are multidisciplinary, and communication among many healthcare providers is required to provide successful care. Surgeons expressed concern that CISs minimise or eliminate this communication. For CIS success, it is important that communication lines remain open to discuss clinical issues.^{10 17}

Medical situations are often complex and multidisciplinary. CISs were thought to be a streamlined process that lacked flexibility to adapt to non-routine or complex cases.²¹ High-volume, low-acuity, low-complexity and low-variation surgeries are most suitable for CISs, and low-volume and complex procedures are not.²⁰ Complex cases are not suitable for pooling, with differences in operating technique, surgeon criteria for surgery, potential medicolegal implications and devaluing the operation or operator.²¹

Common themes for patients and surgeons

Two shared themes emerged between patients and surgeons. Both groups felt that CISs promoted greater equity in access to surgical care. Patients defined equity as fairness within the triage evaluation and booking process, with all referrals evaluated and scheduled using the same criteria for care. ‘Participants agreed that implementing CISs would increase equity and access to care, given that CISs triage patients based on objective criteria such as urgency and necessity’.²⁰ Surgeons defined equity as equal access to patient referrals, increasing equity among surgeons—especially young, female or racialised, and reducing the influence of social ties.²⁰

Quality and design were defined by surgeons as the CIS’s ability to capture non-measurement-based feedback. ‘CIS performance should have quantitative and qualitative forms of measurement, including patient acceptance and quality of care. Quantifiable measures mentioned by participants included case numbers, case efficiency and wait times’,²⁰ with those that oppose pooled waitlists possibly feeling isolated, as greater throughput and efficiency continue to be pushed through.¹⁹

Patients saw quality and design as the competency of a surgeon to safely deliver a successful surgery, with a visible structure for patients to monitor quality and outcomes for each surgeon.¹⁵ Patients preferred that CISs provided ‘(1) a process to monitor quality and outcomes and to be able to trust that the surgeon to whom they are being referred does high-quality work and that (2) the difference in likely waiting times between choosing a particular surgeon and choosing the first-available surgeon’.

Discussion

This systematic review analysed the patients’ and surgeons’ experience introducing a CIS as a solution to waitlist management. The review revealed a notable scarcity of publications that incorporate end-user perspectives on CIS implementation, despite the fact that such involvement is crucial to the success of health system change and ‘vital to the success of health information technology implementation’.²⁹ Ensuring CIS throughput from referral to surgery requires buy-in from all stakeholders, not just patients and surgeons. Referring physicians, surgeons, patients and allied healthcare professionals must collaborate to codesign a foundational model and referral form. Further system adoption and implementation should build on this framework, promoting consistency while allowing flexibility and professional autonomy. In the CIS design process, it is important to incorporate the benefits identified in figure 2, while remaining mindful of the barriers—notably, the absence of end-user engagement.^{18 20} With timely and effective surgery being the foundation of a CIS model, additional barriers to consider are surgeon self-interest, poor triage of discretionary or elective procedures, inadequate triage in cases with debatable operative indications, and a model of care that overlooks social and psychological dimensions of illness.

Our review highlights that while common themes exist, patients and providers often interpret these themes differently. For example, ‘equity’ for patients refers to fair triage and timely surgery bookings, whereas for surgeons it means equal access to referrals. Similarly, ‘quality and design’ from the patient’s perspective refers to visibility of individual surgeon outcomes, while surgeons emphasise the importance of capturing non-measurement-based feedback. Integrating both definitions during CIS design is key to fostering stakeholder buy-in and adoption.

Some limitations of our study include the inherent challenges associated with qualitative methodology, which is often less transparent, difficult to reproduce and can be complex to evaluate and interpret. Additionally, there was a limited number of studies identified that were directly relevant to our research question, possibly constraining the depth of our analysis. Two other publications have synthesised patient and surgeon experiences with CISs. A 2017 systematic review by Damani et al found high patient satisfaction and acceptability, but mixed responses from general practitioners and surgeons. Concerns were raised around CIS communication, flexibility, infrastructure, acceptability and interprofessional cooperation. In contrast, our review includes more recent publications (post-2017), emphasising end-user perspectives and drawing from a broader Canadian context.³⁰

In 2021, the Canadian Agency for Drugs and Technologies in Health (CADTH) published a Health Technology Review on Canadian ‘Central intake systems in surgical services’. This review highlighted similar benefits of CISs—such as defined triage pathways, investment in health system resources, quality improvement, system integration and transparency. There were also similar challenges, including change management, competing priorities, funding, strategic alignment and maintaining momentum. Historically, social and patient perspectives have been underrepresented in health technology reviews, however, such input is essential for clinicians and policy makers evaluating system-level changes. Notably, CADTH’s review did not include patient perspectives on CIS implementation—a gap our systematic review aimed to address.^{14 31}

Conclusion

As jurisdictions continue to design and implement CISs, it is important to ensure all end-users have not only a seat but a voice at the table. In Canada’s healthcare system, decision-making power among end-users appears to be unevenly distributed. Balancing these voices is vital to ensure inclusive, equitable and effective system design and reform. Further research is needed to explore end-user perspectives on CIS as a strategy for waitlist management. This is a key component in assessing whether CISs can effectively reduce surgical wait times and help meet national benchmark targets.

When implemented thoughtfully, CISs can support more efficient referral and waitlist processes, however, they represent just one part of the broader effort needed to address surgical backlogs in Canada. System-wide efficiency is essential—from initial referral through to postoperative rehabilitation. The success of any quality improvement initiative relies on incorporating the perspectives of all end-users throughout its development and implementation.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.