The Health Information and Quality Authority (HIQA) has today published for consultation draft recommended thresholds that patients should meet before they are referred for a number of scheduled procedures. This latest phase in a series of health technology assessments (HTAs) focuses on thresholds for a number of spinal procedures and hand surgeries.

The purpose of these HTAs is to evaluate the potential impact of introducing clinical referral or treatment thresholds for such procedures within the publicly funded healthcare system and to provide advice on potential minimum thresholds, which should help decide whether a patient is a suitable candidate for treatment. With the demand for healthcare services increasing, it is important that only those patients who will benefit from a procedure are referred.

HIQA’s Director of Health Technology Assessment Dr Máirín Ryan said: “The purpose of these assessments is to ensure that the patients most in need of treatment receive it as quickly as possible. For scheduled procedures, it is vital that the right patients are referred for treatment at the right time, potentially releasing capacity and resources without causing harm or reducing benefit.”

“There are numerous benefits to having thresholds, including reduced inappropriate referral of patients for scheduled procedures. Increased clarity around referral or treatment thresholds for GPs could potentially minimise the referral of patients who do not then proceed to surgery, for example, and should help ensure that patients have timely access to beneficial care in the most appropriate treatment setting.”

“The draft reports provide evidence-based advice on potential referral or treatment thresholds for procedures where effectiveness may be limited for some patients unless undertaken within strict clinical criteria. We are interested in receiving feedback on them and will revise the reports as appropriate based on the information received.”
HIQA convened a multidisciplinary Expert Advisory Group to guide the process and provide expert advice and information. The completed reports will be submitted to the HSE and to the Minister for Health.

Dr Ryan concluded by saying: “The reports will enable the HSE to make an informed, evidence-based decision when considering if specific thresholds should apply to certain scheduled procedures currently provided by the public healthcare system.”

The consultation on these draft recommended referral thresholds for certain scheduled procedures will run until 6 September 2013. 

* Please note the consultation has been extended until 16 September.

Further Information: 

Please contact: Marty Whelan, Head of Communications and Stakeholder Engagement 01 814 7480 / 086 2447 623 mwhelan@hiqa.ie

Notes to the Editor: 

• HIQA is the statutory organisation in Ireland with a responsibility to carry out national health technology assessments (HTAs) and to develop guidelines for the conduct of HTAs across our healthcare system.
• The procedures which are included in Phase II of a series of HTAs include:
  • Release of Carpal tunnel
  • Surgery for Dupuytren’s Contracture
  • Ganglion Cyst Surgery
  • Surgery for trigger finger/thumb
  • Spinal injections for pain due to degenerative lumbar spine disease
  • Vertebroplasty and kyphoplasty for osteoporotic vertebral compression fractures
  • Radiofrequency lesioning for chronic spinal pain
  • Surgery for adult degenerative lumbar spine disease
  • Spinal Cord Stimulation for chronic pain

• Supporting documents include the ‘Background and Methods – Phase II’ and ‘Ethical Analysis’ documents.
• Carpal tunnel syndrome is caused by compression of the median nerve running through the wrist, resulting in numbness, weakness or tingling in the hand. It occurs in people of all ages, though peak incidence occurs between the ages of 50 and 60 years, with women more likely to be affected than men. Surgical release of the carpal tunnel can relieve carpal tunnel syndrome.
• Dupuytren’s disease is a disorder characterised by the appearance of firm pits, nodules or cords in the palm of the hand. This may extend to the fingers and cause them to flex inwards, in which case the disease is known as Dupuytren’s contracture. Surgery can restore function and correct deformity.
• Ganglion cysts are benign, fluid filled growths that usually form near a joint capsule, tendon or tendon sheath. Cysts can develop suddenly or over a period of time and some may resolve spontaneously. They can occur beside any joint in the body, but are most commonly associated with the wrist, hand and fingers. Ganglion cysts can be surgically excised.
• Trigger finger is a painful condition caused by the inflammation or thickening and narrowing of the sheath for the flexor tendon of a finger. If the condition worsens, the finger may get stuck in a bent position, then suddenly pop straight. Eventually, it may not straighten fully and instead become locked in flexion or extension. Surgical trigger finger release can provide a permanent cure.
• Spinal injections are one type of minimally-invasive interventional procedure used in managing back pain either as an independent procedure or in conjunction with other modalities of care. Typically for therapeutic purposes, drugs administered via these injections will include a mix of corticosteroids and local anaesthetics. These injections will result in some pain relief in the short term.
• Spinal cord stimulation delivers repetitive electrical impulses of varying width, duration and intensity to the spinal cord. This stimulation of the dorsal columns of the spinal cord aims to modify the patient’s perception of pain.
• Radiofrequency lesioning procedures are increasingly being used to provide long term pain relief in adults with chronic spinal pain. X-ray imaging is used to guide an electrode to the nerve supplying a painful joint. Classical RFablation involves application of uninterrupted heat (60-80ºC) for a predetermined amount of time to destroy the sensory nerve fibres. Pulsed RF uses short bursts of electrical current of a high voltage without heating the tissue enough to cause coagulation (less than 42ºC). Both procedures aim to interrupt the pain signals to provide relief.
• Vertebroplasty is a minimally-invasive surgical procedure that involves injection of a cement-like material, under X-ray guidance, into the vertebral body to stabilise and strengthen collapsed or crushed bone. During kyphoplasty, a balloon is inserted into the vertebral body and inflated, elevating the fracture and allowing return to a more normal position. A cavity is also created inside the vertebrae for cement injection.
• Surgical approaches to the management of degenerative lumbar spine disease include discectomy, decompression surgery and spinal fusion. Discectomy involves removal of disc material to relieve pressure on the nerve tissue. Decompression surgery can include a combination of procedures, including discectomy, designed to relieve pressure on the spinal cord or nerve roots caused by disc herniation or stenosis of the spinal canal. Where degenerative lumbar disease or prior decompression surgery has resulted in spinal instability, spinal fusion may be required to join two or more vertebrae together.